Basic Information
| Provider Information | |||||||||
| NPI: | 1790784007 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PENA | ||||||||
| FirstName: | PEDRO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 STATE ST | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165500002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148776182 | ||||||||
| FaxNumber: | 8148776149 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 STATE ST | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165500002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148776182 | ||||||||
| FaxNumber: | 8148776149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 05/16/2013 | ||||||||
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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 | 2085R0204X | MD015257E | PA | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1068921 | 01 | WV | W. VIRGINIA WORKERS COMP | OTHER | 300120916 | 01 | PA | RR MEDICARE | OTHER | 00025445602 | 01 | NY | UNIVERA | OTHER | 1521688 | 01 | PA | GATEWAY | OTHER | 0018379020003 | 05 | PA | MEDICAID | 02146761 | 01 | NY | NY MEDICAL ASSISTANCE | OTHER | 2231365 | 01 | OH | OH MEDICAL ASSISTANCE | OTHER | 3369068 | 01 | PA | AETNA | OTHER | 304576 | 01 | PA | UPMC | OTHER | 118180 | 01 | PA | UNISON | OTHER | 722913 | 01 | PA | BLUE SHIELD | OTHER |