Provider Demographics
NPI:1306382270
Name:ROBERT A BAZYLAK, M.D.
Entity Type:Organization
Organization Name:ROBERT A BAZYLAK, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT, PHYSICIAN SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-333-5267
Mailing Address - Street 1:1034 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-2945
Mailing Address - Country:US
Mailing Address - Phone:814-382-0221
Mailing Address - Fax:814-382-0231
Practice Address - Street 1:12387 CONNEAUT LAKE RD
Practice Address - Street 2:
Practice Address - City:CONNEAUT LAKE
Practice Address - State:PA
Practice Address - Zip Code:16316-4203
Practice Address - Country:US
Practice Address - Phone:814-382-0221
Practice Address - Fax:814-382-0231
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRENCH CREEK INTERNAL MEDICINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-16
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD014601E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty