Basic Information
| Provider Information | |||||||||
| NPI: | 1699735746 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLETTA | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 252 | ||||||||
| Address2: | |||||||||
| City: | BRYN MAWR | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104366529 | ||||||||
| FaxNumber: | 6104366479 | ||||||||
| Practice Location | |||||||||
| Address1: | 830 OLD LANCASTER RD | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | BRYN MAWR | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105271185 | ||||||||
| FaxNumber: | 6105271940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD023702E | PA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 001054786004 | 05 | PA | MEDICAID |