Provider Demographics
NPI:1972166940
Name:PENNSYLVANIA SPINE TO FOOT PAIN SPECIALISTS GP
Entity Type:Organization
Organization Name:PENNSYLVANIA SPINE TO FOOT PAIN SPECIALISTS GP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ALYSSA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PICCILLO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:570-417-4755
Mailing Address - Street 1:PO BOX 40068
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-0068
Mailing Address - Country:US
Mailing Address - Phone:267-909-9594
Mailing Address - Fax:
Practice Address - Street 1:500 FAIRMOUNT AVE FL 1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19123-2890
Practice Address - Country:US
Practice Address - Phone:267-909-9594
Practice Address - Fax:267-367-5559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-16
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty