Provider Demographics
NPI:1639159510
Name:BOCCAGNO, PHILLIP A (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:A
Last Name:BOCCAGNO
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 1:231 NORTHERN BLVD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-9189
Mailing Address - Country:US
Mailing Address - Phone:570-587-4113
Mailing Address - Fax:570-587-7703
Practice Address - Street 1:231 NORTHERN BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411-9189
Practice Address - Country:US
Practice Address - Phone:570-587-4113
Practice Address - Fax:570-587-7703
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD022568E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00093540Medicaid
PA00093540Medicaid
B40917Medicare UPIN