Provider Demographics
NPI:1124015797
Name:RIDELLA, PETER JAMES (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JAMES
Last Name:RIDELLA
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 1:1111 FRANKLIN ST
Mailing Address - Street 2:SUITE 140
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-4330
Mailing Address - Country:US
Mailing Address - Phone:814-535-5554
Mailing Address - Fax:814-535-5255
Practice Address - Street 1:1111 FRANKLIN ST
Practice Address - Street 2:SUITE 140
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-4330
Practice Address - Country:US
Practice Address - Phone:814-535-5554
Practice Address - Fax:814-535-5255
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD018887E207X00000X, 207XS0106X, 207XS0117X, 207XX0004X, 207XX0005X, 207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007978670002Medicaid
PA200008503Medicare PIN
PA067755F84Medicare PIN
PA0007978670002Medicaid