Provider Demographics
NPI:1609873181
Name:LUELLEN, JOHN RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RUSSELL
Last Name:LUELLEN
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 1:9011 PEREGRINE DR
Mailing Address - Street 2:
Mailing Address - City:GIBSONIA
Mailing Address - State:PA
Mailing Address - Zip Code:15044-8061
Mailing Address - Country:US
Mailing Address - Phone:412-913-5634
Mailing Address - Fax:
Practice Address - Street 1:1000 DUTCH RIDGE RD
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:PA
Practice Address - Zip Code:15009-9727
Practice Address - Country:US
Practice Address - Phone:724-773-3418
Practice Address - Fax:724-773-4648
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD065589L207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017116600001Medicaid
PA0017116600011Medicaid
OH2229190Medicaid
PA016428NJRMedicare PIN
PA0017116600001Medicaid
PA0017116600011Medicaid
PACG2169Medicare PIN
PA15604Medicare PIN