Healthcare Provider Details

I. General information

NPI: 1013911528
Provider Name (Legal Business Name): LYNN ANN COLAIACOVO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 SHENANGO VALLEY FWY STE 1
HERMITAGE PA
16148-2536
US

IV. Provider business mailing address

2501 SHENANGO VALLEY FWY STE 1
HERMITAGE PA
16148-2536
US

V. Phone/Fax

Practice location:
  • Phone: 724-983-1820
  • Fax: 724-983-1822
Mailing address:
  • Phone: 724-983-1820
  • Fax: 724-983-1822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD057934L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: