Healthcare Provider Details

I. General information

NPI: 1568442325
Provider Name (Legal Business Name): TRACEY CARMELLINI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 11/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 W BALTIMORE PIKE
WEST GROVE PA
19390-9459
US

IV. Provider business mailing address

301 S 7TH AVE STE 135
WEST READING PA
19611-1442
US

V. Phone/Fax

Practice location:
  • Phone: 610-869-1235
  • Fax:
Mailing address:
  • Phone: 484-628-4580
  • Fax: 610-736-0721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD07057BL
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: