Provider Demographics
NPI:1962417626
Name:KETZAN, TIBOR (MD)
Entity type:Individual
Prefix:
First Name:TIBOR
Middle Name:
Last Name:KETZAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:720 BLACKBURN ROAD
Mailing Address - Street 2:SEWICKLEY VALLEY HOSPITAL
Mailing Address - City:SEWICKLEY
Mailing Address - State:PA
Mailing Address - Zip Code:15143
Mailing Address - Country:US
Mailing Address - Phone:412-749-7127
Mailing Address - Fax:412-749-4268
Practice Address - Street 1:720 BLACKBURN ROAD
Practice Address - Street 2:SEWICKLEY VALLEY HOSPITAL
Practice Address - City:SEWICKLEY
Practice Address - State:PA
Practice Address - Zip Code:15143
Practice Address - Country:US
Practice Address - Phone:412-749-7127
Practice Address - Fax:412-749-4268
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD021936E208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0024749OtherUS HEALTHCARE
PA5803OtherHEALTH ASSURANCE ADVANTRA
PA0994356Medicaid
PA159417OtherHIGHMARK BCS SECURITY BLU
PA1007226OtherGATEWAY
PA23215676400OtherHEALTH ASSURANCE
OH23215676400OtherOHIO WORKERS COMP
PAP003957OtherCHAMPUS
PA1265992OtherCIGNA
WV23215676400OtherW VIRGINIA WORKERS COMP
PA1007226OtherGATEWAY
PA159417OtherHIGHMARK BCS SECURITY BLU