Provider Demographics
NPI:1780623306
Name:EBBERT, COLLEEN K (MD)
Entity type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:K
Last Name:EBBERT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 WATERCREST WAY
Mailing Address - Street 2:SUITE 630
Mailing Address - City:CHESWICK
Mailing Address - State:PA
Mailing Address - Zip Code:15024-1370
Mailing Address - Country:US
Mailing Address - Phone:724-274-9451
Mailing Address - Fax:724-274-9370
Practice Address - Street 1:200 DELAFIELD RD STE 2030
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15215-3214
Practice Address - Country:US
Practice Address - Phone:412-782-2101
Practice Address - Fax:412-782-2108
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD056817L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080112250OtherRAILROAD MEDICARE
PA175950OtherHIGHMARK
PA0015936470002Medicaid
PA175950Medicare ID - Type Unspecified
080112250OtherRAILROAD MEDICARE