Provider Demographics
NPI:1205807815
Name:RICHARD CHWASTIAK
Entity type:Organization
Organization Name:RICHARD CHWASTIAK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:CHWASTIAK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:570-668-5170
Mailing Address - Street 1:617 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:TAMAQUA
Mailing Address - State:PA
Mailing Address - Zip Code:18252-2206
Mailing Address - Country:US
Mailing Address - Phone:570-668-5170
Mailing Address - Fax:570-668-5171
Practice Address - Street 1:617 E BROAD ST
Practice Address - Street 2:
Practice Address - City:TAMAQUA
Practice Address - State:PA
Practice Address - Zip Code:18252-2206
Practice Address - Country:US
Practice Address - Phone:570-668-5170
Practice Address - Fax:570-668-5171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-31
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA02609400OtherCAPITAL BLUE CROSS
1338692OtherHIGHMARK BS
PA480000509OtherTRAVELERS MEDICARE
PA0787880001Medicare NSC
PA153345Medicare PIN