Provider Demographics
NPI:1457436883
Name:SUTILLA, CONSTANCE B (MD)
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:B
Last Name:SUTILLA
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 1:255 W LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:PAOLI
Mailing Address - State:PA
Mailing Address - Zip Code:19301-1763
Mailing Address - Country:US
Mailing Address - Phone:610-429-0693
Mailing Address - Fax:
Practice Address - Street 1:255 W LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1763
Practice Address - Country:US
Practice Address - Phone:610-429-0693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD052888L2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0847310OtherAETNA
PA489045OtherBLUE SHIELD PA
PA0149034502OtherAMERICHOICE
PA0730214000OtherKEYSTONE HEALTHPLAN EAST
PA0014903450007Medicaid
PAG17252Medicare UPIN
PA0014903450007Medicaid