=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144238825
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICK J COLARUSSO D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2006
-----------------------------------------------------
Last Update Date | 10/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1320 BROADCASTING RD STE 200
-----------------------------------------------------
City | WYOMISSING
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19610-3222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-372-8995
-----------------------------------------------------
Fax | 610-685-5984
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1320 BROADCASTING RD STE 200
-----------------------------------------------------
City | WYOMISSING
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19610-3222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-372-8995
-----------------------------------------------------
Fax | 610-685-5984
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RX0202X
-----------------------------------------------------
Taxonomy Name | Medical Oncology Physician
-----------------------------------------------------
License Number | OS007188L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------