Provider Demographics
NPI:1952423857
Name:PODIATRY ASSOCIATES OF ERIE INC
Entity type:Organization
Organization Name:PODIATRY ASSOCIATES OF ERIE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:DIBACCO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:814-864-4874
Mailing Address - Street 1:4402 PEACH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-1358
Mailing Address - Country:US
Mailing Address - Phone:814-864-4874
Mailing Address - Fax:814-864-4877
Practice Address - Street 1:4402 PEACH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-1358
Practice Address - Country:US
Practice Address - Phone:814-864-4874
Practice Address - Fax:814-864-4877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0241581Medicaid
PA000501005-0001Medicaid
OH0241581Medicaid
PA000501005-0001Medicaid