MEDICARE: SANJEEV JETHMALANI MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RP1001X	Pulmonary Disease Physician	MD045240E	PA

General Provider Information

NPI Number	:	1588668545
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANJEEV JETHMALANI MD

Provider Business Mailing Address
First Line	:	911 LIGONIER ST
Second Line	:	STE 204
City	:	LATROBE
State	:	PA
Zip	:	15650-1805
Country	:	US
Telephone Number	:	724-537-2210
Fax Number	:	724-537-2545

Provider Business Practice Location Address
First Line	:	911 LIGONIER ST
Second Line	:	STE 204
City	:	LATROBE
State	:	PA
Zip	:	15650-1805
Country	:	US
Telephone Number	:	724-537-2210
Fax Number	:	724-537-2545

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2005
Last Update Date	:	07/08/2007

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