Provider Demographics
NPI:1558366971
Name:PASQUALICCHIO, GARY E (DO)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:E
Last Name:PASQUALICCHIO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1034 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-2945
Mailing Address - Country:US
Mailing Address - Phone:814-373-4296
Mailing Address - Fax:814-724-2196
Practice Address - Street 1:991 PARK AVE
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-3344
Practice Address - Country:US
Practice Address - Phone:814-373-4298
Practice Address - Fax:814-724-2196
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS003597L207Q00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1011024470003Medicaid
PAP000010OtherGATEWAY
OH0567211OtherOH MEDICAL ASSISTANCE
PA214426OtherUPMC
PA049521OtherBLUE SHIELD
PA151367OtherUNISON
PA828383OtherAETNA
NY00051085003OtherUNIVERA
NY01267270OtherNY MEDICAL ASSISTANCE
PA110211322OtherRR MEDICARE
PA049521OtherBLUE SHIELD
PA214426OtherUPMC