MEDICARE: KATHLEEN D ETZEL MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	MD049657L	PA
2	2085B0100X	Body Imaging Physician	MD049657L	PA
3	2085N0904X	Nuclear Radiology Physician	MD049657L	PA
4	2085P0229X	Pediatric Radiology Physician	MD049657L	PA
5	2085R0204X	Vascular & Interventional Radiology Physician	MD049657L	PA
6	2085U0001X	Diagnostic Ultrasound Physician	MD049657L	PA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00143495	OTHER		RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
2	0018069510004	OTHER	MA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	141309	OTHER	BLUE SHIELD

General Provider Information

NPI Number	:	1770531295
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN D ETZEL MD

Provider Business Mailing Address
First Line	:	7 ACEE DRIVE
Second Line	:
City	:	NATRONA HEIGHTS
State	:	PA
Zip	:	15065
Country	:	US
Telephone Number	:	800-223-5544
Fax Number	:	724-294-3206

Provider Business Practice Location Address
First Line	:	406 W OAK STREET
Second Line	:
City	:	TITUSVILLE
State	:	PA
Zip	:	16354
Country	:	US
Telephone Number	:	814-827-1851
Fax Number	:	724-226-4575

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	10/25/2007

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Directions to “ KATHLEEN D ETZEL MD” Practice Location

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