Healthcare Provider Details

I. General information

NPI: 1477797512
Provider Name (Legal Business Name): EDMUND RONALD ANTOSZEWSKI ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2009
Last Update Date: 04/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 DUSS AVE
AMBRIDGE PA
15003-2060
US

IV. Provider business mailing address

10 PEARL AVE
PITTSBURGH PA
15229-2127
US

V. Phone/Fax

Practice location:
  • Phone: 724-266-2833
  • Fax:
Mailing address:
  • Phone: 412-301-0641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT004248
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: