MEDICARE: DR. PETRA DANIELISZ 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	207R00000X	Internal Medicine Physician	MD062597L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376655456
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PETRA DANIELISZ M.D.

Provider Business Mailing Address
First Line	:	161 INNSBRUCK DR
Second Line	:
City	:	EMPORIUM
State	:	PA
Zip	:	15834-3841
Country	:	US
Telephone Number	:	814-486-2046
Fax Number	:

Provider Business Practice Location Address
First Line	:	81 CLARION RD
Second Line	:
City	:	JOHNSONBURG
State	:	PA
Zip	:	15845-1656
Country	:	US
Telephone Number	:	814-389-4411
Fax Number	:	814-389-4142

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	02/02/2021

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