Provider Demographics
NPI:1740269596
Name:CENTRAL PA PODIATRY ASSOCIATES, PC
Entity type:Organization
Organization Name:CENTRAL PA PODIATRY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:E
Authorized Official - Last Name:MRDJENOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:814-946-1075
Mailing Address - Street 1:2727 BEALE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601-1705
Mailing Address - Country:US
Mailing Address - Phone:814-946-1075
Mailing Address - Fax:814-946-4076
Practice Address - Street 1:2727 BEALE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-1705
Practice Address - Country:US
Practice Address - Phone:814-946-1075
Practice Address - Fax:814-946-4076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-11
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiologyGroup - Single Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0857830000OtherINDEPENDENCE PPO BLUE GRP
PA1115690001OtherDME GROUP
CC2226OtherRR MEDICARE
H26758OtherPREFERRED HEALTHCARE
PA826758OtherBLUE SHIELD GROUP
H26758OtherAMERIHEALTH
PA1024437OtherGATEWAY GROUP
H26758OtherPREMIER BLUE
PA826758OtherBLUE SHIELD GROUP
=========OtherUMWA
=========OtherGEISINGER
=========OtherTAX ID NUMBER
PA826758LGCMedicare ID - Type UnspecifiedMEDICARE GROUP