Healthcare Provider Details

I. General information

NPI: 1225236722
Provider Name (Legal Business Name): RUDOLPH ANTONCIC III, M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 10/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 WALNUT ST
MCKEESPORT PA
15132-6327
US

IV. Provider business mailing address

2255 GREENOCK BUENA VISTA RD
MCKEESPORT PA
15135-3007
US

V. Phone/Fax

Practice location:
  • Phone: 412-751-4400
  • Fax: 412-751-4881
Mailing address:
  • Phone: 412-754-3770
  • Fax: 412-896-0627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD418006
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier1385401
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerHIGHMARK BLUE SHIELD
# 2
Identifier1521997
Identifier TypeOTHER
Identifier State
Identifier IssuerGATEWAY HEALTH PLAN
# 3
Identifier308210
Identifier TypeOTHER
Identifier State
Identifier IssuerUPMC HEALTH PLAN
# 4
Identifier0019003720001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 5
Identifier75640
Identifier TypeOTHER
Identifier State
Identifier IssuerAETNA
# 6
Identifier262531
Identifier TypeOTHER
Identifier State
Identifier IssuerHEALTH AMERICA
# 7
Identifier125036
Identifier TypeOTHER
Identifier State
Identifier IssuerUNISON HEALTH PLAN
# 8
Identifier2074615000
Identifier TypeOTHER
Identifier State
Identifier IssuerINDEPENDENCE BLUE

VIII. Authorized Official

Name: DR. RUDOLPH ANDREW ANTONCIC III
Title or Position: OWNER
Credential: M.D.
Phone: 412-754-3770