Healthcare Provider Details

I. General information

NPI: 1740230978
Provider Name (Legal Business Name): GRACIELA CATALINA BIANCO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 06/23/2020
Certification Date: 06/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 AIRPORT ROAD STE 134 BELTWAY COMMONS
HAZLETON PA
18202-3840
US

IV. Provider business mailing address

100 N ACADEMY AVE
DANVILLE PA
17822-4903
US

V. Phone/Fax

Practice location:
  • Phone: 570-501-7512
  • Fax: 570-501-7515
Mailing address:
  • Phone: 570-271-6144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD430628
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1018576950001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: