Basic Information
Provider Information | |||||||||
NPI: | 1508853706 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOLNAR | ||||||||
FirstName: | THEODORE | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3572 BRODHEAD RD | ||||||||
Address2: | SUITE 201 | ||||||||
City: | MONACA | ||||||||
State: | PA | ||||||||
PostalCode: | 150613101 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7247286539 | ||||||||
FaxNumber: | 7247287416 | ||||||||
Practice Location | |||||||||
Address1: | 1000 DUTCH RIDGE RD | ||||||||
Address2: |   | ||||||||
City: | BEAVER | ||||||||
State: | PA | ||||||||
PostalCode: | 150099727 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7247734567 | ||||||||
FaxNumber: | 7247289729 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/03/2005 | ||||||||
LastUpdateDate: | 10/15/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD033032E | PA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | MO407971 | 01 | PA | HIGHMARK | OTHER | 0011282620012 | 05 | PA |   | MEDICAID | 3810005657 | 05 | WV |   | MEDICAID | 0011282620009 | 05 | PA |   | MEDICAID | 001856443 | 05 | PA |   | MEDICAID |