Healthcare Provider Details

I. General information

NPI: 1881646859
Provider Name (Legal Business Name): PROGRESSIVE PHYSICIAN ASSOC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 12/16/2022
Certification Date: 12/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 HIGHLAND AVE SUITE 130
BETHLEHEM PA
18017-9424
US

IV. Provider business mailing address

95 HIGHLAND AVE SUITE 130
BETHLEHEM PA
18017-9424
US

V. Phone/Fax

Practice location:
  • Phone: 610-868-1100
  • Fax: 610-868-1111
Mailing address:
  • Phone: 610-868-1100
  • Fax: 610-868-1111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number StatePA

VIII. Authorized Official

Name: SUSANNE DEANGELO
Title or Position: ADMINISTRATIVE CREDENTIALING COORDI
Credential:
Phone: 610-868-1100