Provider Demographics
NPI:1336129212
Name:BIANCARELLI, SUSAN MARIE (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:BIANCARELLI
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 1:407 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:JESSUP
Mailing Address - State:PA
Mailing Address - Zip Code:18434-1415
Mailing Address - Country:US
Mailing Address - Phone:570-383-7922
Mailing Address - Fax:570-383-5450
Practice Address - Street 1:407 3RD AVE
Practice Address - Street 2:
Practice Address - City:JESSUP
Practice Address - State:PA
Practice Address - Zip Code:18434-1415
Practice Address - Country:US
Practice Address - Phone:570-383-7922
Practice Address - Fax:570-383-5450
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD043641E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001194811Medicaid
E36812Medicare UPIN
PA001194811Medicaid