Provider Demographics
NPI:1902127095
Name:PRAKORB MEDICAL ASSOCIATE INC.
Entity Type:Organization
Organization Name:PRAKORB MEDICAL ASSOCIATE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PRAKORB
Authorized Official - Middle Name:
Authorized Official - Last Name:ISARIYAWONGSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:724-785-9696
Mailing Address - Street 1:129 SIMPSON RD
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15417-9689
Mailing Address - Country:US
Mailing Address - Phone:724-785-9696
Mailing Address - Fax:724-785-7225
Practice Address - Street 1:129 SIMPSON RD
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15417-9689
Practice Address - Country:US
Practice Address - Phone:724-785-9696
Practice Address - Fax:724-785-7225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-13
Last Update Date:2010-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA033993L261QM1300X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000586924 0003Medicaid
PA000586924 0003Medicaid
PA129649Medicare PIN