Provider Demographics
NPI:1851543516
Name:YESALAVAGE, MAX A
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:A
Last Name:YESALAVAGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 S 18TH ST
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-5622
Mailing Address - Country:US
Mailing Address - Phone:610-628-8372
Mailing Address - Fax:610-628-8648
Practice Address - Street 1:1200 S CEDAR CREST BLVD
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6202
Practice Address - Country:US
Practice Address - Phone:610-402-9099
Practice Address - Fax:610-402-9029
Is Sole Proprietor?:No
Enumeration Date:2008-10-14
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN518009-L163W00000X
PA081789367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1024154190002Medicaid
PA3633568000OtherIBC
PA9358458OtherAETNA
PA121176OtherGEISINGER
PA2082635OtherFIRST PRIORITY
PA50081140OtherCAPITAL ADVANTAGE
PA11945331OtherCAQH
PA1585282OtherGATEWAY
PA2082635OtherHIGHMARK
PA9358458OtherAETNA
PA142035QCYMedicare PIN