Healthcare Provider Details

I. General information

NPI: 1962975615
Provider Name (Legal Business Name): PT FAMILY MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2019
Last Update Date: 02/09/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2057 STATE ROUTE 130
JEANNETTE PA
15644-3801
US

IV. Provider business mailing address

2057 STATE ROUTE 130
JEANNETTE PA
15644-3801
US

V. Phone/Fax

Practice location:
  • Phone: 724-527-2700
  • Fax: 724-527-2705
Mailing address:
  • Phone: 724-527-2700
  • Fax: 724-527-2705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: KEVIN M WONG
Title or Position: OWNER
Credential: MD
Phone: 724-527-2700