Healthcare Provider Details

I. General information

NPI: 1235422759
Provider Name (Legal Business Name): LYCEUM PHYSICAL MEDICINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2011
Last Update Date: 08/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6062 RIDGE AVENUE
PHILADELPHIA PA
19128
US

IV. Provider business mailing address

6062 RIDGE AVENUE
PHILADELPHIA PA
19128
US

V. Phone/Fax

Practice location:
  • Phone: 215-508-5555
  • Fax:
Mailing address:
  • Phone: 215-508-5555
  • Fax: 215-508-5554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD034915E
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberMD032971E
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM J PEZZELLO
Title or Position: OWNER
Credential: DC
Phone: 215-508-5555