Provider Demographics
NPI:1801862693
Name:PENDLETON, TIMOTHY PAUL (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:PAUL
Last Name:PENDLETON
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 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1440
Mailing Address - Country:US
Mailing Address - Phone:814-849-8329
Mailing Address - Fax:814-849-5441
Practice Address - Street 1:111 SUMMIT STREET
Practice Address - Street 2:
Practice Address - City:BROOKVILLE
Practice Address - State:PA
Practice Address - Zip Code:15825
Practice Address - Country:US
Practice Address - Phone:814-849-8329
Practice Address - Fax:814-849-5441
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53094173000000X
PAMD428157207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No173000000XOther Service ProvidersLegal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA612414900OtherBLACK LUNG
PA101770225Medicaid
PA1486953OtherAETNA
PA104242OtherGEISINGER
PA612414900OtherBLACK LUNG