# LYCEUM PHYSICAL MEDICINE, PC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1235422759
- **Authorized official:** WILLIAM J PEZZELLO DC (OWNER)
- **Authorized official phone:** (215) 508-5555

## Contact information

- **Practice address:** 6062 RIDGE AVENUE, PHILADELPHIA, PA 19128
- **Practice address phone:** (215) 508-5555
- **Mailing address:** 6062 RIDGE AVENUE, PHILADELPHIA, PA 19128
- **Mailing address phone:** (215) 508-5555
- **Mailing address fax:** (215) 508-5554

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208100000X | Physical Medicine & Rehabilitation Physician | — | NULL | Yes |
| 208100000X | Physical Medicine & Rehabilitation Physician | — | — | Yes |
| 208D00000X | General Practice Physician | MD034915E | PA | — |
| 332B00000X | Durable Medical Equipment & Medical Supplies | MD032971E | PA | — |

## Other

- **Enumeration date:** 05/17/2011
- **Last updated:** 08/10/2015