Provider Demographics
NPI:1053382747
Name:MEDWICK, GERALD R (DO)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:R
Last Name:MEDWICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 DUTCH RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:PA
Mailing Address - Zip Code:15009-9727
Mailing Address - Country:US
Mailing Address - Phone:724-773-7616
Mailing Address - Fax:724-773-4673
Practice Address - Street 1:1000 DUTCH RIDGE RD
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:PA
Practice Address - Zip Code:15009-9727
Practice Address - Country:US
Practice Address - Phone:724-773-7616
Practice Address - Fax:724-773-4673
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS004695L207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001090657Medicaid
PA001090657Medicaid
PA107338Medicare ID - Type Unspecified