Provider Demographics
NPI:1720050289
Name:DERIENZO FAMILY PRACTICE
Entity Type:Organization
Organization Name:DERIENZO FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:UMBERTO
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:DERIENZO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:724-483-3581
Mailing Address - Street 1:17 ARENTZEN BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLEROI
Mailing Address - State:PA
Mailing Address - Zip Code:15022-1085
Mailing Address - Country:US
Mailing Address - Phone:724-483-3581
Mailing Address - Fax:724-483-3483
Practice Address - Street 1:17 ARENTZEN BLVD
Practice Address - Street 2:
Practice Address - City:CHARLEROI
Practice Address - State:PA
Practice Address - Zip Code:15022-1085
Practice Address - Country:US
Practice Address - Phone:724-483-3581
Practice Address - Fax:724-483-3483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
077444Medicare ID - Type Unspecified