Healthcare Provider Details

I. General information

NPI: 1659455988
Provider Name (Legal Business Name): AVELLA FAMILY PRACTICE,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 CAMPBELL DR BOX 187
AVELLA PA
15312-2738
US

IV. Provider business mailing address

1394 AVELLA RD
AVELLA PA
15312-3302
US

V. Phone/Fax

Practice location:
  • Phone: 724-587-3472
  • Fax: 724-587-5947
Mailing address:
  • Phone: 724-587-0296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD063186L
License Number StatePA

VIII. Authorized Official

Name: DR. SEAN MATTHEW PORBIN
Title or Position: OWNER
Credential: M.D.
Phone: 724-587-3472