Provider Demographics
NPI:1104822543
Name:STACHELEK, CONRAD J (MD)
Entity Type:Individual
Prefix:
First Name:CONRAD
Middle Name:J
Last Name:STACHELEK
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 1:2508 MYRTLE STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-2700
Mailing Address - Country:US
Mailing Address - Phone:814-452-5400
Mailing Address - Fax:814-454-2003
Practice Address - Street 1:2508 MYRTLE STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-2700
Practice Address - Country:US
Practice Address - Phone:814-452-5400
Practice Address - Fax:814-454-2003
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2020-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD049426L2085R0203X
PAMD0494262085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001411566Medicaid
OH000839144OtherHIGHMARK-OHIO
PA0014115660001Medicaid
OH0919948Medicaid
OH000839144OtherHIGHMARK-OHIO
PA729693Medicare PIN
E57329Medicare UPIN
PA920002051Medicare PIN