Provider Demographics
NPI:1528024619
Name:THEODORE A BUCCILLI JR DPM
Entity Type:Organization
Organization Name:THEODORE A BUCCILLI JR DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CERIMELE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-633-3445
Mailing Address - Street 1:116 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TALLMADGE
Mailing Address - State:OH
Mailing Address - Zip Code:44278-2328
Mailing Address - Country:US
Mailing Address - Phone:330-633-3445
Mailing Address - Fax:330-633-6028
Practice Address - Street 1:116 EAST AVE
Practice Address - Street 2:
Practice Address - City:TALLMADGE
Practice Address - State:OH
Practice Address - Zip Code:44278-2328
Practice Address - Country:US
Practice Address - Phone:330-633-3445
Practice Address - Fax:330-633-6028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003352213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
V04013Medicare UPIN