Basic Information
| Provider Information | |||||||||
| NPI: | 1174593958 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ATTANASIO | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 W RITNER ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191454324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2153362145 | ||||||||
| FaxNumber: | 2153365732 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 W RITNER ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191454324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2153362145 | ||||||||
| FaxNumber: | 2153365732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 12/27/2016 | ||||||||
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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 | 207Q00000X | OS0008637L | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 25MB06296800 | NJ | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 07292032 | 05 | PA | MEDICAID |