Basic Information
| Provider Information | |||||||||
| NPI: | 1730103706 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEHALLO | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | JON | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 833 CHESTNUT ST STE 520 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003219999 | ||||||||
| FaxNumber: | 2673393761 | ||||||||
| Practice Location | |||||||||
| Address1: | 925 CHESTNUT ST | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2673393500 | ||||||||
| FaxNumber: | 2155030580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 02/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | OS-012486 | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2123312000 | 01 | PA | IBC | OTHER | 3215014 | 01 | PA | AETNA | OTHER | P2954746 | 01 | PA | OXFORD | OTHER | 4412252 | 01 | CIGNA | OTHER |