=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902057045
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BARON T. DENNISTON M.D.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2008
-----------------------------------------------------
Last Update Date | 10/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 E 8TH ST
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16501-1269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-456-1863
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 150 E 8TH ST
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16501-1269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-456-1863
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAN
-----------------------------------------------------
Name | DR. BARON T. DENNISTON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 814-456-1863
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TP0016X
-----------------------------------------------------
Taxonomy Name | Prescribing (Medical) Psychologist
-----------------------------------------------------
License Number | MD044333L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------