Provider Demographics
NPI:1578500104
Name:RICCELLI, ANTONIO MARISO (MD)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:MARISO
Last Name:RICCELLI
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 1:1000 BOWER HILL ROAD
Mailing Address - Street 2:ATTN ST CLAIR HOSPITAL - AFFILIATE BILLING - PAMALYN
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15243-1873
Mailing Address - Country:US
Mailing Address - Phone:412-942-2548
Mailing Address - Fax:
Practice Address - Street 1:5301 GROVE RD STE 631
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15236-1693
Practice Address - Country:US
Practice Address - Phone:412-942-9105
Practice Address - Fax:412-942-9109
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD044948L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1000525OtherGATEWAY
PA0012765050004Medicaid
RI710168OtherHIGHMARK
PA0012765050004Medicaid
F16496Medicare UPIN