=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578500104
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTONIO MARISO RICCELLI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2006
-----------------------------------------------------
Last Update Date | 03/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5301 GROVE RD STE 631
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15236-1693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-942-9105
-----------------------------------------------------
Fax | 412-942-9109
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 BOWER HILL ROAD ATTN ST CLAIR HOSPITAL - AFFILIATE BILLING - PAMALYN
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15243-1873
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-942-2548
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | MD044948L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------