Basic Information
| Provider Information | |||||||||
| NPI: | 1720197890 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PULMONARY AND SLEEP MEDICINE OF CENTRAL PA PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 145 HOSPITAL AVE | ||||||||
| Address2: | STE 101 | ||||||||
| City: | DUBOIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 15801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143755305 | ||||||||
| FaxNumber: | 8143755307 | ||||||||
| Practice Location | |||||||||
| Address1: | 145 HOSPITAL AVE | ||||||||
| Address2: | STE 101 | ||||||||
| City: | DUBOIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 15801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143755305 | ||||||||
| FaxNumber: | 8143755307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 03/25/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ILLUZZI | ||||||||
| AuthorizedOfficialFirstName: | ANGELO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT OF CORPORATION | ||||||||
| AuthorizedOfficialTelephone: | 8143755305 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 1695 | 01 | GEISINGER | OTHER | 1013140640002 | 05 | PA | MEDICAID |