Healthcare Provider Details

I. General information

NPI: 1639170442
Provider Name (Legal Business Name): EDWARD C KETYER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1370 WASHINGTON PIKE SUITE 107
BRIDGEVILLE PA
15017-2839
US

IV. Provider business mailing address

1370 WASHINGTON PIKE SUITE 107
BRIDGEVILLE PA
15017-2839
US

V. Phone/Fax

Practice location:
  • Phone: 412-221-0160
  • Fax: 412-221-0860
Mailing address:
  • Phone: 412-221-0160
  • Fax: 412-221-0860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD045079E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: