NPIMap

Individual provider Active NPI

Anthony Tavella, PA-C

  • Physician Assistant
  • Brodheadsville, PA
National Provider Identifier
1316783459
Registry record updated Jul 8, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
MA065717 Issued in PA
Practice address
111 Route 715 Ste 104
Brodheadsville, PA 18322-7101
Phone
(272) 212-0434
Fax
(866) 230-8056
NPI assigned
Jul 8, 2024
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jul 8, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X MA065717 PA Primary

Addresses

Primary practice location

111 Route 715 Ste 104
Brodheadsville, PA 18322-7101

Mailing address

111 Route 715 Ste 104
Brodheadsville, PA 18322-7101
Phone (272) 212-0434

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20240722002339 PA Practitioner - Physician Assistant 6103362587 Reassigns benefits to 6 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2024
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
St Lukes Physician Group IncGroup PAC ID 6709798333, 2,161 clinicians

Practice addresses (Care Compare)

111 Route 715
Brodheadsville, PA 18322-7101

360 W Riddle St
Coaldale, PA 18218-1027
Phone (570) 645-8127

801 Ostrm St
Bethlehem, PA 18015-1000

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
MA065717PAMDPhysician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
St Luke'S Physician Group Inc CurrentSince Aug 26, 2024 Accepting new patients
St. Luke'S Physician Group, Inc. CurrentSince Aug 26, 2024 Accepting new patients
St. Luke'S Physician Group, Inc Past Accepting new patients

Locations

1510 Fawn Valley Dr
Brodheadsville, PA 18322
Phone (570) 402-0700

111 Route 715
Ste 104
Brodheadsvlle, PA 18322
Phone (272) 212-0435

801 Ostrum St
Fountain Hill, PA 18015
Phone (610) 954-2200

Organizations & group practices 9

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 8

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1720396800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1720396800000",
    "number": "1316783459",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "111 ROUTE 715 STE 104",
            "city": "BRODHEADSVILLE",
            "state": "PA",
            "postal_code": "183227101",
            "telephone_number": "272-212-0434"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "111 ROUTE 715 STE 104",
            "city": "BRODHEADSVILLE",
            "state": "PA",
            "postal_code": "183227101",
            "telephone_number": "272-212-0434",
            "fax_number": "866-230-8056"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "TAVELLA",
        "first_name": "ANTHONY",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2024-07-08",
        "last_updated": "2024-07-08",
        "certification_date": "2024-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "PA",
            "license": "MA065717",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Brodheadsville, PA

Sources for this page

Verify at the official NPI Registry.