Basic Information
| Provider Information | |||||||||
| NPI: | 1821099011 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMALL | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 490 E NORTH AVE STE 500 | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152124765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4123598860 | ||||||||
| FaxNumber: | 4123598809 | ||||||||
| Practice Location | |||||||||
| Address1: | 490 E NORTH AVE STE 500 | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152124765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4123598860 | ||||||||
| FaxNumber: | 4123598809 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 10/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0600X | MD049217L | PA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 2084N0400X | MD049217L | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 001408650 | 05 | PA | MEDICAID | 10936641 | 01 | CAQH | OTHER |