Basic Information
Provider Information | |||||||||
NPI: | 1154386068 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CANTAGALLO | ||||||||
FirstName: | VAL | ||||||||
MiddleName: | RAYMOND | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 W ELM ST | ||||||||
Address2: | SUITE 100 | ||||||||
City: | CONSHOHOCKEN | ||||||||
State: | PA | ||||||||
PostalCode: | 194282007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6105676967 | ||||||||
FaxNumber: | 6105676170 | ||||||||
Practice Location | |||||||||
Address1: | 75 E STREET RD | ||||||||
Address2: |   | ||||||||
City: | FEASTERVILLE TREVOSE | ||||||||
State: | PA | ||||||||
PostalCode: | 190536047 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2676841047 | ||||||||
FaxNumber: | 2676841047 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/20/2006 | ||||||||
LastUpdateDate: | 03/27/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD020564E | PA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0058321000 | 01 | PA | KHPE PROVIDER# | OTHER | 026948 | 01 | PA | PA BS PROVIDER# | OTHER | 37088MD020564E | 01 | PA | HEALTHPARTNERS | OTHER | 1007545120003 | 05 | PA |   | MEDICAID | 1256068 | 01 | PA | AETNA USHC HMO | OTHER | 4306878 | 01 | PA | AETNA USHC PPO | OTHER | 203261266 | 01 | PA | COVENTRY | OTHER | 30033137 | 01 | PA | KMHP | OTHER | 6794809 | 01 | PA | CIGNA | OTHER | 0058321000 | 01 | PA | IBC | OTHER | 62176278 | 01 | PA | MULTIPLAN | OTHER | 203261266 | 01 | PA | UNITEDHEALTHCARE | OTHER |