Provider Demographics
NPI:1790787547
Name:KINSELLA, MARIO
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:KINSELLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W 12TH ST STE C
Mailing Address - Street 2:SUITE C
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-4500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 W 12TH ST STE C
Practice Address - Street 2:SUITE C
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-4500
Practice Address - Country:US
Practice Address - Phone:814-877-8730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-046952-L207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001260828Medicaid
PA149933Medicare PIN
PA0012608280006Medicaid
PA0012608280004Medicaid
PA11006187OtherRAILROAD MEDICARE