Provider Demographics
NPI:1932141447
Name:LULTSCHIK, PETER (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:LULTSCHIK
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 1:7 GLASSWORKS RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:15338-9507
Mailing Address - Country:US
Mailing Address - Phone:724-943-3308
Mailing Address - Fax:724-943-3310
Practice Address - Street 1:751 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-2559
Practice Address - Country:US
Practice Address - Phone:814-333-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD046576L207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012988430002Medicaid
F46425Medicare UPIN
PA186245SA6Medicare ID - Type Unspecified