Basic Information
| Provider Information | |||||||||
| NPI: | 1346240116 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACOLINO | ||||||||
| FirstName: | MARCIE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7056 GERMANTOWN AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191191826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152472996 | ||||||||
| FaxNumber: | 2152477504 | ||||||||
| Practice Location | |||||||||
| Address1: | 7056 GERMANTOWN AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191191826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152472996 | ||||||||
| FaxNumber: | 2152477504 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD057889L | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1090409 | 01 | PA | KEY MERCY PROVIDER ID | OTHER | 0055732001 | 01 | PA | IBC PROVIDER NUMBER | OTHER | 01600250 | 01 | PA | MEDICAL ASSISTANCE | OTHER | 582735 | 01 | PA | AETNA | OTHER |