Healthcare Provider Details

I. General information

NPI: 1780445403
Provider Name (Legal Business Name): MARIANO JOSEPH MUSUMECI III PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MARIO MUSUMECI PA-C

II. Dates (important events)

Enumeration Date: 01/19/2024
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1118 W BALTIMORE PIKE
MEDIA PA
19063-6104
US

IV. Provider business mailing address

833 CHESTNUT ST STE 520
PHILADELPHIA PA
19107-4430
US

V. Phone/Fax

Practice location:
  • Phone: 800-321-9999
  • Fax: 267-479-1321
Mailing address:
  • Phone: 609-677-7003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA065463
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: