Provider Demographics
NPI:1730743931
Name:MARCELLO, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MARCELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:MARCELLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:4498 MAIN/HARLEM RD SUITE 24
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226
Mailing Address - Country:US
Mailing Address - Phone:716-839-1550
Mailing Address - Fax:716-839-1696
Practice Address - Street 1:4498 MAIN/HARLEM RD SUITE 24
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226
Practice Address - Country:US
Practice Address - Phone:716-839-1550
Practice Address - Fax:716-839-1696
Is Sole Proprietor?:No
Enumeration Date:2019-04-24
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011840-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ100132514OtherPT