MEDICARE: PODIATRY ASSOCIATES OF ERIE INC

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	213ES0131X	Foot Surgery Podiatrist

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952423857
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PODIATRY ASSOCIATES OF ERIE INC

Provider Business Mailing Address
First Line	:	4402 PEACH ST
Second Line	:
City	:	ERIE
State	:	PA
Zip	:	16509-1358
Country	:	US
Telephone Number	:	814-864-4874
Fax Number	:	814-864-4877

Provider Business Practice Location Address
First Line	:	4402 PEACH ST
Second Line	:
City	:	ERIE
State	:	PA
Zip	:	16509-1358
Country	:	US
Telephone Number	:	814-864-4874
Fax Number	:	814-864-4877

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RICHARD D. DIBACCO
Credential	:	DPM
Telephone Number	:	814-864-4874

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	08/22/2020

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