Healthcare Provider Details

I. General information

NPI: 1487805693
Provider Name (Legal Business Name): FRG CENTRAL PA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2008
Last Update Date: 05/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 E 2ND ST
COUDERSPORT PA
16915-8161
US

IV. Provider business mailing address

PO BOX 60
PITTSBURGH PA
15230-0060
US

V. Phone/Fax

Practice location:
  • Phone: 814-274-9300
  • Fax:
Mailing address:
  • Phone: 412-937-5726
  • Fax: 412-937-5706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY J. PISULA
Title or Position: COO
Credential:
Phone: 412-551-0011