Provider Demographics
NPI:1386745768
Name:GEROLD, MARK (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:GEROLD
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 1:6402 ROUTE 30
Mailing Address - Street 2:
Mailing Address - City:JEANNETTE
Mailing Address - State:PA
Mailing Address - Zip Code:15644-3168
Mailing Address - Country:US
Mailing Address - Phone:724-523-5505
Mailing Address - Fax:
Practice Address - Street 1:6402 ROUTE 30
Practice Address - Street 2:
Practice Address - City:JEANNETTE
Practice Address - State:PA
Practice Address - Zip Code:15644-3168
Practice Address - Country:US
Practice Address - Phone:724-523-5505
Practice Address - Fax:724-527-6416
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301073796207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4625154Medicaid
MI080021729OtherBLUE SHIELD
MI080021729OtherBLUE SHIELD
MI4625154Medicaid