Provider Demographics
NPI:1013968734
Name:PEDONE, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PEDONE
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 1:792 GALLITZIN ROAD
Mailing Address - Street 2:
Mailing Address - City:CRESSON
Mailing Address - State:PA
Mailing Address - Zip Code:16630
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 9TH AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-2415
Practice Address - Country:US
Practice Address - Phone:814-941-8811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS013689L207Q00000X
PAOS013689207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA056175OtherGROUP MEDICARE PIN
PA1019306320001Medicaid
PA056175OtherGROUP MEDICARE PIN