Provider Demographics
NPI:1841887494
Name:CENTRAL PA PODIATRY LLC
Entity type:Organization
Organization Name:CENTRAL PA PODIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:BARANIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-201-2309
Mailing Address - Street 1:914 S 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-6247
Mailing Address - Country:US
Mailing Address - Phone:814-201-2309
Mailing Address - Fax:814-201-2389
Practice Address - Street 1:914 S 12TH ST
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-6247
Practice Address - Country:US
Practice Address - Phone:814-201-2309
Practice Address - Fax:814-201-2389
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL PA CARDIOLOGY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1902884950OtherDR. GERALD GRONBORG
PA1487632428OtherDR. DONALD MRDJENOVICH
PA1029762890001Medicaid