Basic Information
| Provider Information | |||||||||
| NPI: | 1972639334 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAPUCAO | ||||||||
| FirstName: | JOEL | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 S. BRYN MAWR AVE | ||||||||
| Address2: | PSYCHIATRIC UNIT | ||||||||
| City: | BRYN MAWR | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190103121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4843374286 | ||||||||
| FaxNumber: | 4843374293 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 S. BRYN MAWR AVE | ||||||||
| Address2: | PSYCHIATRIC UNIT | ||||||||
| City: | BRYN MAWR | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190103121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4843374286 | ||||||||
| FaxNumber: | 4843374293 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 01/13/2012 | ||||||||
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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 | 2084P0800X | MD069783L | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1021248410002 | 05 | PA | MEDICAID |