Provider Demographics
NPI:1336177443
Name:KOSTELAC, PAULINE HRICISAK (DO)
Entity Type:Individual
Prefix:
First Name:PAULINE
Middle Name:HRICISAK
Last Name:KOSTELAC
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:PAULINE
Other - Middle Name:MARIE
Other - Last Name:HRICISAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7 DOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:570-837-2185
Practice Address - Street 1:555 GETTYSBURG PIKE STE C300
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17055-5206
Practice Address - Country:US
Practice Address - Phone:717-458-8840
Practice Address - Fax:717-795-4138
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS007429L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0070574900003Medicaid
PA733353Medicare ID - Type Unspecified
PA733353OtherHIGHMARK BLUE SHIELD
PAF51455Medicare UPIN
GA080121473OtherPALMETTO GBA - RAILROAD