Provider Demographics
NPI:1033157631
Name:PASTERNAK, EDMOND III (DO)
Entity Type:Individual
Prefix:
First Name:EDMOND
Middle Name:
Last Name:PASTERNAK
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 75113
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-5113
Mailing Address - Country:US
Mailing Address - Phone:304-422-1666
Mailing Address - Fax:904-346-0113
Practice Address - Street 1:799 FARSON ST EMERGENCY DEPT
Practice Address - Street 2:
Practice Address - City:BELPRE
Practice Address - State:OH
Practice Address - Zip Code:45714-1044
Practice Address - Country:US
Practice Address - Phone:740-401-1150
Practice Address - Fax:740-401-1155
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1651207P00000X
OH34006231207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1042767OtherWV WORK COMP
OH2055618Medicaid
OHP01132020OtherRAILROAD MEDICARE
WV0048637000Medicaid
OH2055618Medicaid
WVPA0849123Medicare ID - Type Unspecified
WV1042767OtherWV WORK COMP
OH2055618Medicaid