Basic Information
| Provider Information | |||||||||
| NPI: | 1932282738 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KANELLITSAS | ||||||||
| FirstName: | IOANNA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 HOSPITAL AVE | ||||||||
| Address2: | |||||||||
| City: | DU BOIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158011440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143716172 | ||||||||
| FaxNumber: | 8143713921 | ||||||||
| Practice Location | |||||||||
| Address1: | 145 HOSPITAL AVE | ||||||||
| Address2: | SUITE 315 | ||||||||
| City: | DU BOIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158011462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143716172 | ||||||||
| FaxNumber: | 8143713921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 04/26/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MD451406 | PA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 353894 | 01 | PA | MEDICARE PTAN- INDIVIDUAL | OTHER | 102920926 | 05 | PA | MEDICAID |