MEDICARE: PETER VASSALLUZZO D.O.

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	OS-006575L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0543451000	OTHER	PA	KEYSTONE

General Provider Information

NPI Number	:	1871656009
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETER VASSALLUZZO D.O.

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	:	PHYSICIAN
Name	:	DR. PETER VASSALLUZZO
Credential	:	DO
Telephone Number	:	215-725-8111

Provider Enumeration Date	:	12/19/2006
Last Update Date	:	03/19/2013

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