Healthcare Provider Details

I. General information

NPI: 1407842016
Provider Name (Legal Business Name): PHILIP DEMETRIOS KONDYLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 11/13/2023
Certification Date: 11/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 W 23RD ST STE 201
ERIE PA
16502-2858
US

IV. Provider business mailing address

145 W 23RD ST STE 201
ERIE PA
16502-2858
US

V. Phone/Fax

Practice location:
  • Phone: 814-453-2777
  • Fax: 814-453-2779
Mailing address:
  • Phone: 814-453-2777
  • Fax: 814-453-2779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberMD062356L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: