Provider Demographics
NPI:1497751002
Name:KISKI VALLEY COMMUNITY MEDICINE, PC
Entity Type:Organization
Organization Name:KISKI VALLEY COMMUNITY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:KUPAS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:724-478-2999
Mailing Address - Street 1:310 SOUTH SECOND STREET
Mailing Address - Street 2:
Mailing Address - City:APOLLO
Mailing Address - State:PA
Mailing Address - Zip Code:15613-1111
Mailing Address - Country:US
Mailing Address - Phone:724-478-2999
Mailing Address - Fax:724-478-3005
Practice Address - Street 1:310 S 2ND ST
Practice Address - Street 2:
Practice Address - City:APOLLO
Practice Address - State:PA
Practice Address - Zip Code:15613-1150
Practice Address - Country:US
Practice Address - Phone:724-478-2999
Practice Address - Fax:724-478-3005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-28
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0S008135L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015371560003Medicaid
PA257824OtherHIGHMARK
PA257824OtherHIGHMARK
G12853Medicare UPIN