Provider Demographics
NPI:1376546358
Name:STEFANOVSKI, NICK (MD)
Entity Type:Individual
Prefix:
First Name:NICK
Middle Name:
Last Name:STEFANOVSKI
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 1:100 PEACH ST STE 400
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1423
Mailing Address - Country:US
Mailing Address - Phone:814-877-9100
Mailing Address - Fax:814-454-8470
Practice Address - Street 1:100 PEACH ST STE 400
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-1423
Practice Address - Country:US
Practice Address - Phone:814-877-9100
Practice Address - Fax:814-454-8470
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD039774E207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012321170001Medicaid
E66436Medicare UPIN
644132J7MMedicare ID - Type Unspecified