Healthcare Provider Details

I. General information

NPI: 1528480720
Provider Name (Legal Business Name): BRENTWOOD MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2014
Last Update Date: 01/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3720 BROWNSVILLE RD
PITTSBURGH PA
15227-3520
US

IV. Provider business mailing address

3720 BROWNSVILLE RD
PITTSBURGH PA
15227-3520
US

V. Phone/Fax

Practice location:
  • Phone: 412-882-9455
  • Fax: 412-884-6149
Mailing address:
  • Phone: 412-882-9455
  • Fax: 412-884-6149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA056618
License Number StatePA

VIII. Authorized Official

Name: MR. VINCENT LUCCHETTI
Title or Position: ADMINISTRATOR
Credential:
Phone: 412-882-9455