Provider Demographics
NPI:1568404143
Name:VITELLI, SHANNON L (DO)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:VITELLI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:17 IRON BRIDGE DR
Mailing Address - Street 2:STE 100
Mailing Address - City:COLLEGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19426-2042
Mailing Address - Country:US
Mailing Address - Phone:610-489-5782
Mailing Address - Fax:610-489-6418
Practice Address - Street 1:17 IRON BRIDGE DR STE 100
Practice Address - Street 2:
Practice Address - City:COLLEGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19426-2042
Practice Address - Country:US
Practice Address - Phone:484-622-6340
Practice Address - Fax:484-622-6357
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS011868208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA30010139OtherKEYSTONE MERCY
PA3373024OtherAETNA HMO
PA36156-OS011868OtherHEALTH PARTNERS
PA7402478OtherAETNA PPO
PA1523072OtherHIGHMARK BLUE SHIELD
PA2209467000OtherIBC - PC/KHPE
PA2209467000OtherAMERICHOICE/INTERCOUNTY
PA11212082OtherCAQH ID#
PA0019807030001OtherOMAP
PA9514702OtherCIGNA HMO/PPO
PA7402478OtherAETNA PPO
PA11212082OtherCAQH ID#