Provider Demographics
NPI:1851384267
Name:HIERONIMUS, GARY T (DC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:T
Last Name:HIERONIMUS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2275 SWALLOW HILL RD
Mailing Address - Street 2:BUIDING 2600
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15220-1656
Mailing Address - Country:US
Mailing Address - Phone:412-279-4522
Mailing Address - Fax:412-279-3416
Practice Address - Street 1:2275 SWALLOW HILL RD
Practice Address - Street 2:BUIDING 2600
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15220-1656
Practice Address - Country:US
Practice Address - Phone:412-279-4522
Practice Address - Fax:412-279-3416
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC001296L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01659257Medicaid
PA115879FAEMedicare ID - Type Unspecified
PA01659257Medicaid
PAHI115879Medicare ID - Type UnspecifiedMEDICARE/BS #