Basic Information
| Provider Information | |||||||||
| NPI: | 1437119757 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRENDERGAST | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1350 LOCUST ST | ||||||||
| Address2: | SUITE G102 | ||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152194738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4122328494 | ||||||||
| FaxNumber: | 4122328727 | ||||||||
| Practice Location | |||||||||
| Address1: | 1350 LOCUST ST | ||||||||
| Address2: | STE G102 BUILDING C | ||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152194738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4122328494 | ||||||||
| FaxNumber: | 4122328727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 09/13/2011 | ||||||||
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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 | 173000000X | MD038722E | PA | N | Other Service Providers | Legal Medicine | 174400000X | MD038722E | PA | Y | Other Service Providers | Specialist | 173000000X | N | Other Service Providers | Legal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001099400 | 05 | PA | MEDICAID |