Basic Information
| Provider Information | |||||||||
| NPI: | 1700913456 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LODICO | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7000 STONEWOOD DR | ||||||||
| Address2: | STE. 151 | ||||||||
| City: | WEXFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 15090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249330300 | ||||||||
| FaxNumber: | 7249330456 | ||||||||
| Practice Location | |||||||||
| Address1: | 7000 STONEWOOD DR | ||||||||
| Address2: | SUITE 151 | ||||||||
| City: | WEXFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150907376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249330300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 08/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | MD047135L | PA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 174400000X | MD047135L | PA | N | Other Service Providers | Specialist | 207LP2900X | 27284 | WV | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0012859990001 | 05 | PA | MEDICAID |