=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194243584
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTHONY JOSEPH DECARLO M.S., LAT, ATC, CES
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2017
-----------------------------------------------------
Last Update Date | 01/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 FALCON DR
-----------------------------------------------------
City | CONNELLSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15425-5504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-628-1350
-----------------------------------------------------
Fax | 724-628-0280
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 711 BAUGHMAN AVE
-----------------------------------------------------
City | JEANNETTE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15644-2920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-551-5870
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 2000030525
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------