Healthcare Provider Details

I. General information

NPI: 1699756999
Provider Name (Legal Business Name): ITALO MARCELLO BASTIANELLI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 02/19/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FORT GEORGE G. MEADE MEDDAC 2480 LLEWELLYN AVE/SUITE 5800
FORT MEADE MD
20755-5129
US

IV. Provider business mailing address

6455 MACHINE ST BLDG 2501
ABERDEEN PROVING GROUND MD
21005-5213
US

V. Phone/Fax

Practice location:
  • Phone: 410-278-1763
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number25MB05892100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number25MB05892100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: