Provider Demographics
NPI:1972501872
Name:SEBASTIANELLI, MARIO J (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:J
Last Name:SEBASTIANELLI
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 1:1416 MONROE AVE
Mailing Address - Street 2:STE 206
Mailing Address - City:DUNMORE
Mailing Address - State:PA
Mailing Address - Zip Code:18509-2477
Mailing Address - Country:US
Mailing Address - Phone:570-347-5212
Mailing Address - Fax:570-346-4814
Practice Address - Street 1:1416 MONROE AVE
Practice Address - Street 2:STE 206
Practice Address - City:DUNMORE
Practice Address - State:PA
Practice Address - Zip Code:18509-2477
Practice Address - Country:US
Practice Address - Phone:570-347-5212
Practice Address - Fax:570-346-4814
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD0006983E207RN0300X
FLME-11834207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0669080Medicaid
B33402Medicare UPIN
PASE019554Medicare ID - Type Unspecified
PA0669080Medicaid