Healthcare Provider Details

I. General information

NPI: 1396740767
Provider Name (Legal Business Name): JACK TODD WAHRENBERGER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 09/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

249 S 9TH ST
PITTSBURGH PA
15203-1265
US

IV. Provider business mailing address

249 S 9TH ST
PITTSBURGH PA
15203-1265
US

V. Phone/Fax

Practice location:
  • Phone: 412-697-3260
  • Fax:
Mailing address:
  • Phone: 412-697-3260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD 050618 L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: