Provider Demographics
NPI:1568414571
Name:ANSELMO, MARIO T (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:T
Last Name:ANSELMO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:DEPT OF PATHOLOGY
Mailing Address - Street 2:3200 MACCORKLE AVE SE
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304
Mailing Address - Country:US
Mailing Address - Phone:304-388-5550
Mailing Address - Fax:304-388-4352
Practice Address - Street 1:3200 MACCORKLE AVENUE SE
Practice Address - Street 2:PATHOLOGY DEPARTMENT
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304
Practice Address - Country:US
Practice Address - Phone:304-388-5550
Practice Address - Fax:304-388-4352
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2015-11-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WV16616207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F26118Medicare UPIN
AN7181271Medicare PIN
P00858418Medicare PIN
AN4279451Medicare PIN