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General NPI Number Information
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NPI Number | 1396822870
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Entity Type | Organization
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Legal Business Name | PINE STREET DERMATOLOGY, PC
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Dates
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Enumeration Date | 11/01/2006
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Last Update Date | 05/11/2012
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Provider Practice Location Address
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Address Line | 1233 LOCUST ST. SUITE 101
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City | PHILADELPHIA
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State | PA
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Zip | 19107
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Country | US
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Telephone | 215-735-2636
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Fax | 215-735-2634
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Provider Business Mailing Address
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Address Line | 1233 LOCUST ST. SUITE 101
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City | PHILADELPHIA
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State | PA
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Zip | 19107
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Country | US
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Telephone | 215-735-2636
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Fax | 215-735-2634
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SEANA COVELLO
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Credential | MD
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Telephone | 215-574-9101
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | MD067435L
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | MD067435L
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License Number State | PA
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