Provider Demographics
NPI:1134213960
Name:DANIEL R YANICKO JR MD PA
Entity type:Organization
Organization Name:DANIEL R YANICKO JR MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT -- ORTHOPAEDIC SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:YANICKO
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:302-236-1894
Mailing Address - Street 1:465 PINE ST
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-4310
Mailing Address - Country:US
Mailing Address - Phone:302-236-1894
Mailing Address - Fax:
Practice Address - Street 1:465 PINE ST
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-4310
Practice Address - Country:US
Practice Address - Phone:302-236-1894
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0008111207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000041262Medicaid
DEG02449Medicare PIN
B35180Medicare UPIN