Provider Demographics
NPI:1194794057
Name:TYLERDALE FAMILY MEDICINE PC
Entity type:Organization
Organization Name:TYLERDALE FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:KITSKO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:724-222-7240
Mailing Address - Street 1:151 N FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-4307
Mailing Address - Country:US
Mailing Address - Phone:724-222-7240
Mailing Address - Fax:
Practice Address - Street 1:151 N FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-4307
Practice Address - Country:US
Practice Address - Phone:724-222-7240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA124474OtherHIGHMARK BS/KHPW
PA0009402480001Medicaid
PA124474OtherHIGHMARK BS/KHPW