Provider Demographics
NPI:1841227089
Name:STACHOWIAK, EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:STACHOWIAK
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 1:610 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3702
Mailing Address - Country:US
Mailing Address - Phone:570-288-5441
Mailing Address - Fax:570-288-5842
Practice Address - Street 1:ROUTES 940 & 115
Practice Address - Street 2:
Practice Address - City:BLAKESLEE
Practice Address - State:PA
Practice Address - Zip Code:18610
Practice Address - Country:US
Practice Address - Phone:570-646-8745
Practice Address - Fax:570-646-8962
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD044630L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001243308Medicaid
PA0012433080007Medicaid
PA0012433080007Medicaid
E92671Medicare UPIN
679983Medicare ID - Type Unspecified
PA679983L3FMedicare PIN