Provider Demographics
NPI:1356523286
Name:PETER P SIDORIAK
Entity type:Organization
Organization Name:PETER P SIDORIAK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:P
Authorized Official - Last Name:SIDORIAK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:570-622-3668
Mailing Address - Street 1:1851 W END AVE
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-2050
Mailing Address - Country:US
Mailing Address - Phone:570-622-3668
Mailing Address - Fax:570-622-2920
Practice Address - Street 1:1851 W END AVE
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-2050
Practice Address - Country:US
Practice Address - Phone:570-622-3668
Practice Address - Fax:570-622-2920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0485860001Medicare NSC