Provider Demographics
NPI:1144412594
Name:BANKSVILLE MEDICAL, PC
Entity Type:Organization
Organization Name:BANKSVILLE MEDICAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:F
Authorized Official - Last Name:DIEDERICH
Authorized Official - Suffix:I
Authorized Official - Credentials:MD
Authorized Official - Phone:412-341-6650
Mailing Address - Street 1:2508 BANKSVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15216-2802
Mailing Address - Country:US
Mailing Address - Phone:412-341-6650
Mailing Address - Fax:
Practice Address - Street 1:2508 BANKSVILLE AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15216-2802
Practice Address - Country:US
Practice Address - Phone:412-341-6650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-09
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015084300003Medicaid
PA1979748OtherHIGHMARK BC/BS
PA0015084300003Medicaid