=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235422759
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LYCEUM PHYSICAL MEDICINE, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2011
-----------------------------------------------------
Last Update Date | 08/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6062 RIDGE AVENUE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-508-5555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6062 RIDGE AVENUE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-508-5555
-----------------------------------------------------
Fax | 215-508-5554
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WILLIAM J PEZZELLO
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 215-508-5555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | MD034915E
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | MD032971E
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------