Provider Demographics
NPI:1285620906
Name:FIORAVANTI, FRED K (MD)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:K
Last Name:FIORAVANTI
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 1:112 MARWOOD RD
Mailing Address - Street 2:#5000
Mailing Address - City:CABOT
Mailing Address - State:PA
Mailing Address - Zip Code:16023-2239
Mailing Address - Country:US
Mailing Address - Phone:724-352-4448
Mailing Address - Fax:724-352-4412
Practice Address - Street 1:112 MARWOOD RD
Practice Address - Street 2:#5000
Practice Address - City:CABOT
Practice Address - State:PA
Practice Address - Zip Code:16023-2239
Practice Address - Country:US
Practice Address - Phone:724-352-4448
Practice Address - Fax:724-352-4412
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2016-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD025211E207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00100247003Medicaid
PA00100247003Medicaid
PA607535Medicare ID - Type Unspecified