LYCEUM LONGEVITY CENTER PLLC (NPI# 1831666585) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1831666585 |
| Entity Type | Organization |
| Organization Name | LYCEUM LONGEVITY CENTER PLLC |
| Practice Address |
6062 Ridge Ave Philadelphia PA 19128-1647 |
| Practice Telephone | 2155085555 |
| Practice Fax Number | 2155085555 |
| Mailing Telephone | 2155085555 |
| Mailing Fax Number | 2155085555 |
| Enumeration Date | 2018-10-31 |
| Last Update Date | 2019-10-04 |
| Authorized Official Name | WILLIAM J PEZZELLO (CO-FOUNDER) |
| Authorized Official Telephone | 2155085555 |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| N | 111N00000X | Chiropractor | Chiropractic Providers | ||
| N | 2085R0202X |
Radiology Specialization: Diagnostic Radiology |
Allopathic & Osteopathic Physicians | ||
| Y | 174400000X | Specialist | Other Service Providers |
| Street Address |
6062 RIDGE AVE |
| City | PHILADELPHIA |
| State | PA |
| Zip Code | 19128-1647 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1356823959 | Geenander Kaur Raju | Nurse Practitioner | 6062 Ridge Ave, Philadelphia, PA 19128-1647 | 2018-08-30 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1851877179 | Andrew Mermelstein | Podiatrist | 5800 Roxborough Avenue, Philadelphia, PA 19128 | 2018-07-19 |
| 1811499361 | Ursula Wacyk | Social Worker | 6122 Ridge Avenue, Philadelphia, PW 19128 | 2018-03-01 |
| 1417478454 | Chelsea Lynn Roberts | Physician Assistant | 707 Autumn River Run, Philadelphia, PA 19128 | 2017-06-29 |
| 1174060503 | Melody Ann Piranian | Nurse Practitioner | Andorra Pediatrics, 8945 Ridge Ave St 5, Phila, PA 19128 | 2017-01-24 |
| 1154874410 | Meghan Smith | Pharmacist | 5927-59 Ridge Ave, Philadelphia, PA 19128 | 2016-08-03 |
| 1356797880 | Jenna Angelo | Registered Nurse | 457 Spring Lane, Philadelphia, PA 19128 | 2016-05-13 |
| 1689049843 | Newcourtland Senior Centers | Clinic/Center | 4200b Mitchell Street, Suie 1000, Philadelphia, PA 19128 | 2015-12-14 |
| 1235519331 | Merin Wexler | Social Worker | 6060 Ridge Avenue, Suite 210, Philadelphia, PA 19128 | 2015-06-03 |
| 1457754335 | Sarah De Simone | Specialist/Technologist | 318 Fountain Street, Philadelphia, PA 19128 | 2014-10-06 |
| 1609280049 | Sylvia Russianoff | Counselor | 128 Rochelle Avenue, Philadelphia, PA 19128 | 2014-06-13 |
| Find all providers in zip 19128 | ||||
| Taxonomy Code | 174400000X |
| Grouping | Other Service Providers |
| Classification | Specialist |
| An individual educated and trained in an applied knowledge discipline used in the performance of work at a level requiring knowledge and skills beyond or apart from that provided by a general education or liberal arts degree. |
| Notes: Source: Expanded from Webster’s II New Riverside University Dictionary, Boston: Riverside Publishing Company, 1974. |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1174156012 | Sade Yolanda Davis | Specialist | 2414 N Garnet St, Philadelphia, PA 19132-3725 | 2020-02-19 |
| 1356803993 | Larkerra Goodson | Specialist | 1336 Arrott St Apt E15, Philadelphia, PA 19124-3281 | 2019-04-03 |
| 1306302617 | Keisha Robinson | Specialist | 6852 Regent St, Philadelphia, PA 19142-1213 | 2019-02-12 |
| 1740758168 | William Whitaker | Specialist | 1115 E Sanger St, Philadelphia, PA 19124-1130 | 2018-11-02 |
| 1902395536 | Ran Barzilay | Specialist | 3440 Market St, Suite 200, Philadelphia, PA 19104 | 2018-05-09 |
| 1093229668 | Danielle M Marshall | Specialist | 514 Seville St Apt 7, Philadelphia, PA 19128-2737 | 2017-11-19 |
| 1336651017 | Radhia Afif | Specialist | 5943 Weymouth St, Philadelphia, PA 19120-1122 | 2017-11-02 |
| 1306383401 | Helping Hair LLC | Specialist | 930 N 50th St, Philadelphia, PA 19131-5102 | 2017-01-26 |
| 1447796172 | Kristen Halvorson | Specialist | 3411 Cresson St, Apartment 6, Philadelphia, PA 19129-1654 | 2017-01-19 |
| 1174079131 | Sadia Randolph | Specialist | 6718 Paschall Ave, Philadelphia, PA 19142-1809 | 2016-08-30 |
| Find all providers in PHILADELPHIA | ||||
| City | PHILADELPHIA |
| Zip Code | 19128 |
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.