Provider Demographics
NPI:1831807304
Name:EXCELSIA PA, PLLC
Entity type:Organization
Organization Name:EXCELSIA PA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CONSTANTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MISOUL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-933-5678
Mailing Address - Street 1:9601 PULASKI PARK DR STE 417
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-1409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 W ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:GLENOLDEN
Practice Address - State:PA
Practice Address - Zip Code:19036-1101
Practice Address - Country:US
Practice Address - Phone:610-461-6450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty