Provider Demographics
NPI:1710971882
Name:PICKERILL, ROBERT G (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:G
Last Name:PICKERILL
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 1:1107 CLUB DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-1906
Mailing Address - Country:US
Mailing Address - Phone:814-242-0520
Mailing Address - Fax:
Practice Address - Street 1:1086 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-4305
Practice Address - Country:US
Practice Address - Phone:814-242-0520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD019294E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP31109403853OtherION HEALTH
PA87201OtherTHREE RIVERS HEALTH PLAN
PA1025205OtherGATEWAY
PA0009133850004Medicaid
PA547286OtherHIGHMARK BLUE SHIELD
PA0009133850004Medicaid
PA1025205OtherGATEWAY
PA441113112Medicare ID - Type UnspecifiedRR MEDICARE