Basic Information
| Provider Information | |||||||||
| NPI: | 1225363716 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIVAK | ||||||||
| FirstName: | STANLEY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2400 BROWN HILL RD | ||||||||
| Address2: | |||||||||
| City: | YOUNGSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 163713330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8145634563 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2 W CRESCENT PARK | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 163652111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147234973 | ||||||||
| FaxNumber: | 8147236095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2009 | ||||||||
| LastUpdateDate: | 05/15/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD016651E | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1024034900002 | 05 | PA | MEDICAID |