MEDICARE: MARIO KINSELLA

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	MD-046952-L	PA

General Provider Information

NPI Number	:	1790787547
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIO KINSELLA

Provider Business Mailing Address
First Line	:	2500 W 12TH ST STE C
Second Line	:	SUITE C
City	:	ERIE
State	:	PA
Zip	:	16505-4500
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2500 W 12TH ST STE C
Second Line	:	SUITE C
City	:	ERIE
State	:	PA
Zip	:	16505-4500
Country	:	US
Telephone Number	:	814-877-8730
Fax Number	:

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

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	04/06/2021

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Directions to “ MARIO KINSELLA ” Practice Location

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