=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184675274
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN A CONSALVO M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2006
-----------------------------------------------------
Last Update Date | 01/27/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 MAIN ST
-----------------------------------------------------
City | PECKVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18452-2009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-489-7546
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2000 GREEN RD SUITE 300
-----------------------------------------------------
City | ANN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48105-1598
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-995-3764
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | MD025156E
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------