Provider Demographics
NPI:1194901611
Name:MICHAEL J PIETRUSIK DPM
Entity type:Organization
Organization Name:MICHAEL J PIETRUSIK DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PIETRUSIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-822-3411
Mailing Address - Street 1:3277 S PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LACKAWANNA
Mailing Address - State:NY
Mailing Address - Zip Code:14218-3527
Mailing Address - Country:US
Mailing Address - Phone:716-822-3411
Mailing Address - Fax:
Practice Address - Street 1:3277 S PARK AVE
Practice Address - Street 2:
Practice Address - City:LACKAWANNA
Practice Address - State:NY
Practice Address - Zip Code:14218-3527
Practice Address - Country:US
Practice Address - Phone:716-822-3411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN0036341332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00845978Medicaid
NY00845978Medicaid
NYU00115Medicare UPIN
NY0588490001Medicare NSC