Provider Demographics
NPI:1326014580
Name:TANITSKY, MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:TANITSKY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 W COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GAP
Mailing Address - State:PA
Mailing Address - Zip Code:16823-7401
Mailing Address - Country:US
Mailing Address - Phone:814-359-5620
Mailing Address - Fax:814-359-5629
Practice Address - Street 1:550 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:PLEASANT GAP
Practice Address - State:PA
Practice Address - Zip Code:16823-7401
Practice Address - Country:US
Practice Address - Phone:814-359-5620
Practice Address - Fax:814-359-5629
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS003352L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006444740005Medicaid
PAD77456Medicare UPIN
PA0006444740005Medicaid