Provider Demographics
NPI:1124048533
Name:IMRICH, BERNARD J (MD)
Entity type:Individual
Prefix:
First Name:BERNARD
Middle Name:J
Last Name:IMRICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BERNARD
Other - Middle Name:JOHN
Other - Last Name:IMRICH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:110 S PINE ST
Mailing Address - Street 2:
Mailing Address - City:CARMICHAELS
Mailing Address - State:PA
Mailing Address - Zip Code:15320-1264
Mailing Address - Country:US
Mailing Address - Phone:724-966-5019
Mailing Address - Fax:724-966-8952
Practice Address - Street 1:110 S PINE ST
Practice Address - Street 2:
Practice Address - City:CARMICHAELS
Practice Address - State:PA
Practice Address - Zip Code:15320-1264
Practice Address - Country:US
Practice Address - Phone:724-966-5019
Practice Address - Fax:724-966-8952
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD026109E207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP035823OtherCHAMPUS
PA110138OtherBLACK LUNG
PA119281Medicare PIN
PA110138OtherBLACK LUNG