Provider Demographics
NPI:1053304352
Name:SZYDLOWSKI, THADDEUS RAYMOND (MD)
Entity Type:Individual
Prefix:DR
First Name:THADDEUS
Middle Name:RAYMOND
Last Name:SZYDLOWSKI
Suffix:
Gender:M
Credentials:MD
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 300
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-0300
Mailing Address - Country:US
Mailing Address - Phone:717-270-7780
Mailing Address - Fax:717-274-9746
Practice Address - Street 1:761 NORMAN DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7497
Practice Address - Country:US
Practice Address - Phone:717-376-1180
Practice Address - Fax:717-273-6937
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD014356E207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
91402OtherHIGHMARK BLUE SHIELD
50046058OtherCAPITAL BLUE CROSS
151298OtherGATEWAY HEALTH PLAN
PA0006698670002Medicaid
151298OtherGATEWAY HEALTH PLAN
PA0006698670002Medicaid