1619936077 NPI number — FREDERICK L PORKOLAB MD

Table of content: FREDERICK L PORKOLAB MD (NPI 1619936077)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619936077 NPI number — FREDERICK L PORKOLAB MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORKOLAB
Provider First Name:
FREDERICK
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619936077
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2781 LEECHBURG RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOWER BURRELL
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-226-3345
Provider Business Mailing Address Fax Number:
724-226-2415

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4727 FRIENDSHIP AVE
Provider Second Line Business Practice Location Address:
STE 180
Provider Business Practice Location Address City Name:
PITTSBURGH
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15224-1779
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
412-235-5881
Provider Business Practice Location Address Fax Number:
412-235-5878
Provider Enumeration Date:
03/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  MD016838E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0001X , with the licence number: MD016838E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0006875420 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0006875420002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0085813000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0006875420007 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0639027 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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