Provider Demographics
NPI:1871667907
Name:ANTONCIC, RUDOLPH A III (MD)
Entity Type:Individual
Prefix:
First Name:RUDOLPH
Middle Name:A
Last Name:ANTONCIC
Suffix:III
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 1:2255 GREENOCK BUENA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:MCKEESPORT
Mailing Address - State:PA
Mailing Address - Zip Code:15135-3007
Mailing Address - Country:US
Mailing Address - Phone:412-751-4400
Mailing Address - Fax:412-751-4881
Practice Address - Street 1:5301 WALNUT ST
Practice Address - Street 2:
Practice Address - City:MCKEESPORT
Practice Address - State:PA
Practice Address - Zip Code:15132-6327
Practice Address - Country:US
Practice Address - Phone:412-751-4400
Practice Address - Fax:412-751-4881
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD418006207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1342465OtherHIGHMARK BLUE SHIELD
PA2036578000OtherINDEPENDENCE BLUE SHIELD
PA0018735060001Medicaid
PA110236669OtherRR MEDICARE
PA1342465OtherHIGHMARK BLUE SHIELD
PA0018735060001Medicaid