Healthcare Provider Details

I. General information

NPI: 1366435653
Provider Name (Legal Business Name): NORTH CENTRAL PENN PODIATRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 11/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 WEST AVE
WELLSBORO PA
16901-1358
US

IV. Provider business mailing address

103 WEST AVE
WELLSBORO PA
16901-1358
US

V. Phone/Fax

Practice location:
  • Phone: 570-724-5297
  • Fax: 570-724-8793
Mailing address:
  • Phone: 570-724-5297
  • Fax: 570-724-8793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberSC0018534
License Number StatePA

VIII. Authorized Official

Name: STEVAN J ANSELMI
Title or Position: OWNER
Credential: DPM
Phone: 570-724-5297