Basic Information
| Provider Information | |||||||||
| NPI: | 1093798282 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIST | ||||||||
| FirstName: | DARYL | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1088 | ||||||||
| Address2: | |||||||||
| City: | HERMITAGE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 161480088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066608505 | ||||||||
| FaxNumber: | 7066609390 | ||||||||
| Practice Location | |||||||||
| Address1: | 239 EDGEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | TRANSFER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 161541817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7246460400 | ||||||||
| FaxNumber: | 7246460413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 01/25/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | OS003985L | PA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 000856690 0009 | 05 | PA | MEDICAID | 101208491 0001 | 05 | PA | MEDICAID |