Provider Demographics
NPI:1861611303
Name:REYNOLD A. PANETTIERI. M.D.P.C.
Entity type:Organization
Organization Name:REYNOLD A. PANETTIERI. M.D.P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REYNOLD
Authorized Official - Middle Name:A
Authorized Official - Last Name:PANETTIERI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-342-5859
Mailing Address - Street 1:830 SOLLY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-1924
Mailing Address - Country:US
Mailing Address - Phone:215-342-5859
Mailing Address - Fax:215-342-6136
Practice Address - Street 1:830 SOLLY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-1924
Practice Address - Country:US
Practice Address - Phone:215-342-5859
Practice Address - Fax:215-342-6136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD026841L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMD026841LOtherMEDICAL LICENSE LICENSE
PA1184611246OtherTYPE 1 NPI
PA0058288000OtherINDEPENDENCE BLUE CROSS
PA$$$$$$$$$OtherSOCIAL SECURITY #
PA0058288001OtherKEYSTONE HEALTH PLAN EAST
PAAP4484779OtherCONTROL SUBSTANCE REGISTR
PAAP4484779OtherCONTROL SUBSTANCE REGISTR
PAMD026841LOtherMEDICAL LICENSE LICENSE