Basic Information
| Provider Information | |||||||||
| NPI: | 1841393816 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPOLI | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | |||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2413 | ||||||||
| Address2: | |||||||||
| City: | CRANBERRY TWP | ||||||||
| State: | PA | ||||||||
| PostalCode: | 160661413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249359030 | ||||||||
| FaxNumber: | 7247764065 | ||||||||
| Practice Location | |||||||||
| Address1: | 5830 MERIDIAN RD | ||||||||
| Address2: | |||||||||
| City: | GIBSONIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150449668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7244437231 | ||||||||
| FaxNumber: | 7344434467 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | SC-002928-L | PA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 0010721760004 | 05 | PA | MEDICAID | 183240 | 01 | PA | BLUE CROSS BLUE SHIELD | OTHER | 13943 | 01 | PA | ELDERHEALTH | OTHER | 88375 | 05 | PA | MEDICAID | 1362204 | 01 | PA | UNITED MINE WORKERS AMER | OTHER | 183240 | 01 | PA | 65 SPECIAL MEDIGAP BC BS | OTHER | 1504983 | 05 | PA | MEDICAID |