Basic Information
| Provider Information | |||||||||
| NPI: | 1134129349 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DENITTIS | ||||||||
| FirstName: | ALBERT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020A E BOAL AVE | ||||||||
| Address2: | |||||||||
| City: | BOALSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168271509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142378627 | ||||||||
| FaxNumber: | 8142380083 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 E LANCASTER AVE | ||||||||
| Address2: | |||||||||
| City: | WYNNEWOOD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190963450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106452433 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 01/05/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | MD063741L | PA | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 0019014960001 | 05 | PA | MEDICAID |