MEDICARE: PETER VASSALLUZZO DO

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	207Q00000X	Family Medicine Physician	OS006575L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0543451001	OTHER	PA	BLUE SHIELD
2	1152	OTHER	PA	AETNA
3	707562	OTHER	PA	HIGHMARK

General Provider Information

NPI Number	:	1750311148
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER VASSALLUZZO DO

Provider Business Mailing Address
First Line	:	6190 RISING SUN AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19111-6011
Country	:	US
Telephone Number	:	215-725-8111
Fax Number	:	215-742-9501

Provider Business Practice Location Address
First Line	:	6190 RISING SUN AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19111-6011
Country	:	US
Telephone Number	:	215-725-8111
Fax Number	:	215-742-9501

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

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	06/18/2008

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Directions to “ PETER VASSALLUZZO DO” Practice Location

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