Healthcare Provider Details

I. General information

NPI: 1467496273
Provider Name (Legal Business Name): ROBERT R CONCILUS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 GROVE ST
MEADVILLE PA
16335-2945
US

IV. Provider business mailing address

463 PINE ST
MEADVILLE PA
16335-2974
US

V. Phone/Fax

Practice location:
  • Phone: 814-333-5736
  • Fax: 814-333-5819
Mailing address:
  • Phone: 814-333-5872
  • Fax: 814-333-5832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMD027700E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: