Provider Demographics
NPI:1851385421
Name:DETRICK, EARL P (MD)
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:P
Last Name:DETRICK
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:PO BOX 60
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15230-0060
Mailing Address - Country:US
Mailing Address - Phone:412-937-5726
Mailing Address - Fax:
Practice Address - Street 1:700 QUINCY AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-1724
Practice Address - Country:US
Practice Address - Phone:570-307-4225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD025570L2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAA32850Medicare UPIN