Basic Information
| Provider Information | |||||||||
| NPI: | 1205867405 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | D'EMILIO | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | THERESA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RUSSO | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | T | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3421 CONCORD RD | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174029001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178511405 | ||||||||
| FaxNumber: | 7178512479 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 S GEORGE ST | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174033676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178512672 | ||||||||
| FaxNumber: | 7178512479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD022813E | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001024858 | 05 | PA | MEDICAID | 179044 | 01 | PA | UNISON-WMG | OTHER | 145116 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 50057965 | 01 | PA | CAPITAL BLUE CROSS-WMG | OTHER | P002681 | 01 | PA | GATEWAY-WMG | OTHER | 50057545 | 01 | PA | KEYSTONE HEALTH PLAN | OTHER | 20049267 | 01 | PA | AMERIHEALTH MERCY-WMG | OTHER | 2147312 | 01 | PA | MAMSI-WMG | OTHER | 36719 | 01 | PA | GEISINGER HEALTH PLAN | OTHER | 0068849000 | 01 | PA | AMERIHEALTH 65 PA | OTHER | 103030 | 01 | PA | JOHNS HOPKINS | OTHER | 4313675 | 01 | PA | AETNA | OTHER | 650987 | 01 | MD | CAREFIRST MD BCBS | OTHER |