Provider Demographics
NPI:1528480720
Name:BRENTWOOD MEDICAL GROUP
Entity type:Organization
Organization Name:BRENTWOOD MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCCHETTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-882-9455
Mailing Address - Street 1:3720 BROWNSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15227-3520
Mailing Address - Country:US
Mailing Address - Phone:412-882-9455
Mailing Address - Fax:412-884-6149
Practice Address - Street 1:3720 BROWNSVILLE RD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15227-3520
Practice Address - Country:US
Practice Address - Phone:412-882-9455
Practice Address - Fax:412-884-6149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-08
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056618363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty