Provider Demographics
NPI:1962495424
Name:KURELLO, PHILLIP JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:JOHN
Last Name:KURELLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PHILLIP
Other - Middle Name:JOHN
Other - Last Name:KURELLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX C
Mailing Address - Street 2:1051 MOUNTAINVIEW DRIVE
Mailing Address - City:LEHMAN
Mailing Address - State:PA
Mailing Address - Zip Code:18627-0903
Mailing Address - Country:US
Mailing Address - Phone:570-675-4545
Mailing Address - Fax:570-675-7123
Practice Address - Street 1:1051 MOUNTAIN VIEW DR
Practice Address - Street 2:
Practice Address - City:LEHMAN
Practice Address - State:PA
Practice Address - Zip Code:18627-0903
Practice Address - Country:US
Practice Address - Phone:570-675-4545
Practice Address - Fax:570-675-7123
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD039685L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAB35116Medicare UPIN