Provider Demographics
NPI:1952572059
Name:PENYAK, RAYMOND M
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:M
Last Name:PENYAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2135 BUSTARD RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-5724
Mailing Address - Country:US
Mailing Address - Phone:800-473-6925
Mailing Address - Fax:610-584-9767
Practice Address - Street 1:2135 BUSTARD RD
Practice Address - Street 2:SUITE 2
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-5724
Practice Address - Country:US
Practice Address - Phone:800-473-6925
Practice Address - Fax:610-584-9767
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-17
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA6000003509332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018511060001Medicaid