MEDICARE: PRESQUE ISLE FAMILY MEDICINE

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	207Q00000X	Family Medicine Physician	OS007417L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0800122783	OTHER	PA	PALMETTO GBA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	645037	OTHER	PA	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1679628408
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRESQUE ISLE FAMILY MEDICINE

Provider Business Mailing Address
First Line	:	2556 W 12TH ST
Second Line	:
City	:	ERIE
State	:	PA
Zip	:	16505-4508
Country	:	US
Telephone Number	:	814-836-9209
Fax Number	:

Provider Business Practice Location Address
First Line	:	2556 W 12TH ST
Second Line	:
City	:	ERIE
State	:	PA
Zip	:	16505-4508
Country	:	US
Telephone Number	:	814-836-9209
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DOCTOR
Name	:	DAVID C LESSESKI
Credential	:	M.D.
Telephone Number	:	814-836-9209

Provider Enumeration Date	:	01/24/2007
Last Update Date	:	06/17/2014

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Directions to “PRESQUE ISLE FAMILY MEDICINE ” Practice Location

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