Provider Demographics
NPI:1619902178
Name:ALBANESE, ELLENJEANE (MD)
Entity Type:Individual
Prefix:
First Name:ELLENJEANE
Middle Name:
Last Name:ALBANESE
Suffix:
Gender:F
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:PO BOX 447
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-0447
Mailing Address - Country:US
Mailing Address - Phone:814-787-5131
Mailing Address - Fax:814-787-8586
Practice Address - Street 1:HEMLOCK AVE
Practice Address - Street 2:
Practice Address - City:FORCE
Practice Address - State:PA
Practice Address - Zip Code:15841
Practice Address - Country:US
Practice Address - Phone:814-787-5131
Practice Address - Fax:814-787-8586
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-040786-E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001171138Medicaid
PAE58704Medicare UPIN
PA630058Medicare ID - Type Unspecified