Healthcare Provider Details

I. General information

NPI: 1346579224
Provider Name (Legal Business Name): TYRONE MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2009
Last Update Date: 05/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 HOSPITAL DR
TYRONE PA
16686-1827
US

IV. Provider business mailing address

5626 OBERLIN DR SUITE 110
SAN DIEGO CA
92121-1705
US

V. Phone/Fax

Practice location:
  • Phone: 814-684-3101
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License NumberMD050865L
License Number StatePA

VIII. Authorized Official

Name: ANNA M ANNA
Title or Position: CEO
Credential:
Phone: 814-684-1255