Provider Demographics
NPI:1225363716
Name:SIVAK, STANLEY J (MD)
Entity type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:J
Last Name:SIVAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 BROWN HILL RD
Mailing Address - Street 2:
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16371-3330
Mailing Address - Country:US
Mailing Address - Phone:814-563-4563
Mailing Address - Fax:
Practice Address - Street 1:2 W CRESCENT PARK
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-2111
Practice Address - Country:US
Practice Address - Phone:814-723-4973
Practice Address - Fax:814-723-6095
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-16
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD016651E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1024034900002Medicaid
PA1024034900002Medicaid