Provider Demographics
NPI:1023005618
Name:CROCENELLI, THERESA MARIE (MD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:CROCENELLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:974 BEAVER GRADE RD
Mailing Address - Street 2:
Mailing Address - City:MOON TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:15108-2746
Mailing Address - Country:US
Mailing Address - Phone:412-264-6117
Mailing Address - Fax:412-264-6159
Practice Address - Street 1:974 BEAVER GRADE RD
Practice Address - Street 2:
Practice Address - City:MOON TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:15108-2746
Practice Address - Country:US
Practice Address - Phone:412-264-6117
Practice Address - Fax:412-264-6159
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-29
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD070629L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1807242Medicaid
040031H87Medicare ID - Type Unspecified
PA1807242Medicaid