Provider Demographics
NPI:1538139589
Name:TALLERICO, SAMUEL JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:JOSEPH
Last Name:TALLERICO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4815 LIBERTY AVE
Mailing Address - Street 2:SUITE G-25
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15224-2156
Mailing Address - Country:US
Mailing Address - Phone:412-621-1566
Mailing Address - Fax:412-621-8557
Practice Address - Street 1:4815 LIBERTY AVE
Practice Address - Street 2:SUITE G-25
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15224-2156
Practice Address - Country:US
Practice Address - Phone:412-621-1566
Practice Address - Fax:412-621-8557
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD023858E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1016420380001Medicaid
PACG1496Medicare PIN
PAB41322Medicare UPIN
PA1016420380001Medicaid
PAP00042004Medicare PIN