Provider Demographics
NPI:1730109513
Name:CERMAK, MARYBETH (MD)
Entity Type:Individual
Prefix:
First Name:MARYBETH
Middle Name:
Last Name:CERMAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 STATE ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1427
Mailing Address - Country:US
Mailing Address - Phone:814-456-6022
Mailing Address - Fax:814-456-7040
Practice Address - Street 1:300 STATE ST
Practice Address - Street 2:SUITE 205
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-1427
Practice Address - Country:US
Practice Address - Phone:814-456-6022
Practice Address - Fax:814-456-7040
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD043782E207XS0106X
WV15185207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0001203483001Medicaid
PA0001203483001Medicaid
E42754Medicare UPIN