Provider Demographics
NPI:1700981222
Name:S PANTELYAT MD PC
Entity Type:Organization
Organization Name:S PANTELYAT MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUSANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:PANTELYAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-673-1498
Mailing Address - Street 1:2112 WELSH RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115
Mailing Address - Country:US
Mailing Address - Phone:215-673-1498
Mailing Address - Fax:215-673-4299
Practice Address - Street 1:2112 WELSH RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115
Practice Address - Country:US
Practice Address - Phone:215-673-1498
Practice Address - Fax:215-673-4299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4173372084N0400X
NY25MA073820002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA30009182OtherKEYSTONE MERCY
PA3226157OtherAETNA
PA3226157OtherAETNA
H54022Medicare UPIN