Provider Demographics
NPI:1780875757
Name:JAY E ENDRES MDPC
Entity type:Organization
Organization Name:JAY E ENDRES MDPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE TREASURER
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:J
Authorized Official - Last Name:ENDRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-723-3520
Mailing Address - Street 1:12 ELM ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365-2808
Mailing Address - Country:US
Mailing Address - Phone:814-723-3520
Mailing Address - Fax:814-726-2988
Practice Address - Street 1:12 ELM ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-2808
Practice Address - Country:US
Practice Address - Phone:814-723-3520
Practice Address - Fax:814-726-2988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD039470L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA040600Medicare PIN
PAB14540Medicare UPIN
PA422220Medicare PIN