Provider Demographics
NPI:1316998263
Name:FORNELLI, RICK (MD)
Entity type:Individual
Prefix:
First Name:RICK
Middle Name:
Last Name:FORNELLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:380 E BAYFRONT PKWY STE 3
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-2408
Mailing Address - Country:US
Mailing Address - Phone:814-877-9060
Mailing Address - Fax:814-877-9089
Practice Address - Street 1:380 E BAYFRONT PKWY STE 3
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-2408
Practice Address - Country:US
Practice Address - Phone:814-877-9060
Practice Address - Fax:814-877-9089
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD072365L207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018156560001Medicaid
PAH10041Medicare UPIN
PA042133KYFMedicare PIN