Basic Information
| Provider Information | |||||||||
| NPI: | 1790776078 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIRARCHI | ||||||||
| FirstName: | DOMINIC | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 108 LOWTHER ST | ||||||||
| Address2: | INTERNISTS OF CENTRAL PA LTD | ||||||||
| City: | LEMOYNE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170432045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177741366 | ||||||||
| FaxNumber: | 7177744232 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 LOWTHER ST | ||||||||
| Address2: | INTERNISTS OF CENTRAL PA LTD | ||||||||
| City: | LEMOYNE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170432045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177741366 | ||||||||
| FaxNumber: | 7177744232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 07/18/2011 | ||||||||
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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 | 207R00000X | OS009937L | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0018185870001 | 05 | PA | MEDICAID |