Provider Demographics
NPI:1013999747
Name:PELESCHAK, MARK T (CRNA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:PELESCHAK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 TILGHMAN ST
Mailing Address - Street 2:STE 240
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104
Mailing Address - Country:US
Mailing Address - Phone:610-395-4044
Mailing Address - Fax:610-395-5693
Practice Address - Street 1:5000 TILGHMAN ST
Practice Address - Street 2:STE 240
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104
Practice Address - Country:US
Practice Address - Phone:610-395-4044
Practice Address - Fax:610-395-5693
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN297335L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001835828Medicaid
PA50090036OtherCAPITAL BC
PAPE888603OtherHIGHMARK BS (TRADITIONAL INDEMNITY PARTICIPATING)
PA888603WVNMedicare PIN
PA001835828Medicaid
PAPE888603OtherHIGHMARK BS (TRADITIONAL INDEMNITY PARTICIPATING)