Healthcare Provider Details

I. General information

NPI: 1285367722
Provider Name (Legal Business Name): CODY TYLER LANCELLOTTI MS, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2022
Last Update Date: 07/01/2022
Certification Date: 07/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 GREENSPRING VALLEY RD
STEVENSON MD
21153-0641
US

IV. Provider business mailing address

2178 HAIN RD
NEW FREEDOM PA
17349-9268
US

V. Phone/Fax

Practice location:
  • Phone: 717-825-6756
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License NumberA01097
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: