Healthcare Provider Details

I. General information

NPI: 1487959714
Provider Name (Legal Business Name): SMA DEERLAKES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2011
Last Update Date: 01/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 OLD FREEPORT RD SUITE 1B
PITTSBURGH PA
15238-4102
US

IV. Provider business mailing address

1360 OLD FREEPORT RD SUITE 1B
PITTSBURGH PA
15238-4102
US

V. Phone/Fax

Practice location:
  • Phone: 412-767-5212
  • Fax: 412-782-6103
Mailing address:
  • Phone: 412-767-5212
  • Fax: 412-782-6103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD053615L
License Number StatePA

VIII. Authorized Official

Name: DR. MICHAEL E CHISMER
Title or Position: PRESIDENT
Credential: MD
Phone: 412-767-5387