Provider Demographics
NPI:1447253331
Name:LALLY, PATRICK T (MD)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:T
Last Name:LALLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:911 LIGONIER ST
Mailing Address - Street 2:STE 102
Mailing Address - City:LATROBE
Mailing Address - State:PA
Mailing Address - Zip Code:15650-1805
Mailing Address - Country:US
Mailing Address - Phone:724-537-6500
Mailing Address - Fax:724-537-7516
Practice Address - Street 1:911 LIGONIER ST
Practice Address - Street 2:STE 102
Practice Address - City:LATROBE
Practice Address - State:PA
Practice Address - Zip Code:15650-1805
Practice Address - Country:US
Practice Address - Phone:724-537-6500
Practice Address - Fax:724-537-7516
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD024010E207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009123600001Medicaid
PA184854Medicare ID - Type Unspecified
PAB34921Medicare UPIN