Healthcare Provider Details

I. General information

NPI: 1902057045
Provider Name (Legal Business Name): BARON T. DENNISTON M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

150 E 8TH ST
ERIE PA
16501-1269
US

IV. Provider business mailing address

150 E 8TH ST
ERIE PA
16501-1269
US

V. Phone/Fax

Practice location:
  • Phone: 814-456-1863
  • Fax:
Mailing address:
  • Phone: 814-456-1863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License NumberMD044333L
License Number StatePA

VIII. Authorized Official

Name: DR. BARON T. DENNISTON
Title or Position: PHYSICAN
Credential: M.D.
Phone: 814-456-1863