Provider Demographics
NPI:1679628408
Name:PRESQUE ISLE FAMILY MEDICINE
Entity Type:Organization
Organization Name:PRESQUE ISLE FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:LESSESKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-836-9209
Mailing Address - Street 1:2556 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-4508
Mailing Address - Country:US
Mailing Address - Phone:814-836-9209
Mailing Address - Fax:
Practice Address - Street 1:2556 W 12TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-4508
Practice Address - Country:US
Practice Address - Phone:814-836-9209
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS007417L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0800122783OtherPALMETTO GBA
PA0012476390006Medicaid
PA645037OtherBLUE CROSS BLUE SHIELD
PA=========OtherTRICARE
PA645037Medicare ID - Type Unspecified
PA0800122783OtherPALMETTO GBA