Provider Demographics
NPI:1487906285
Name:VERCAUTEREN, MATTHEW (PA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:VERCAUTEREN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 CENTRE AVENUE
Mailing Address - Street 2:SUITE 715
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15232
Mailing Address - Country:US
Mailing Address - Phone:412-623-2025
Mailing Address - Fax:412-623-0329
Practice Address - Street 1:5200 CENTRE AVENUE
Practice Address - Street 2:SUITE 715
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15232
Practice Address - Country:US
Practice Address - Phone:412-623-2025
Practice Address - Fax:412-623-0329
Is Sole Proprietor?:No
Enumeration Date:2012-10-04
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006429363A00000X, 363AS0400X
PAMA056784363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H231320OtherBLUE CROSS GROUP
MI0P62930Medicare PIN