Provider Demographics
NPI:1215989421
Name:PEDIATRIC ASSOCIATES OF LATROBE
Entity type:Organization
Organization Name:PEDIATRIC ASSOCIATES OF LATROBE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:WYSZOMIERSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:724-539-8380
Mailing Address - Street 1:210 WELDON ST
Mailing Address - Street 2:
Mailing Address - City:LATROBE
Mailing Address - State:PA
Mailing Address - Zip Code:15650-1848
Mailing Address - Country:US
Mailing Address - Phone:724-539-8380
Mailing Address - Fax:724-532-0610
Practice Address - Street 1:210 WELDON ST
Practice Address - Street 2:
Practice Address - City:LATROBE
Practice Address - State:PA
Practice Address - Zip Code:15650-1848
Practice Address - Country:US
Practice Address - Phone:724-539-8380
Practice Address - Fax:724-532-0610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1001387Medicaid
PA042486OtherAETNA HMO GP PROVIDER #
PA1012372320001Medicaid
PA033384OtherHIGHMARK GROUP PROVIDER #
PA163793Medicaid
PA163793Medicaid