Healthcare Provider Details

I. General information

NPI: 1033157631
Provider Name (Legal Business Name): EDMOND PASTERNAK III DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 01/27/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

799 FARSON ST EMERGENCY DEPT
BELPRE OH
45714-1044
US

IV. Provider business mailing address

PO BOX 75113
BALTIMORE MD
21275-5113
US

V. Phone/Fax

Practice location:
  • Phone: 740-401-1150
  • Fax: 740-401-1155
Mailing address:
  • Phone: 304-422-1666
  • Fax: 904-346-0113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number1651
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number34006231
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: