MEDICARE: DR. MARY G PONTZER M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	MD-024953E	PA

General Provider Information

NPI Number	:	1225162654
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY G PONTZER M.D.

Provider Business Mailing Address
First Line	:	11676 PERRY HWY STE 2309
Second Line	:
City	:	WEXFORD
State	:	PA
Zip	:	15090-7200
Country	:	US
Telephone Number	:	724-935-6920
Fax Number	:	724-935-6921

Provider Business Practice Location Address
First Line	:	11676 PERRY HWY STE 2309
Second Line	:
City	:	WEXFORD
State	:	PA
Zip	:	15090-7200
Country	:	US
Telephone Number	:	724-935-6920
Fax Number	:	724-935-6921

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	07/08/2007

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