Provider Demographics
NPI:1548539141
Name:DOCTORS AND LAWYERS FOR A DRUG FREE YOUTH
Entity type:Organization
Organization Name:DOCTORS AND LAWYERS FOR A DRUG FREE YOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:RADECKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD, JD
Authorized Official - Phone:814-226-4909
Mailing Address - Street 1:238 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLARION
Mailing Address - State:PA
Mailing Address - Zip Code:16214-1043
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:238 MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARION
Practice Address - State:PA
Practice Address - Zip Code:16214-1043
Practice Address - Country:US
Practice Address - Phone:814-226-4909
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-28
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD015591E2084P0800X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1014336910002Medicaid
PA108405Medicare PIN
PA1014336910002Medicaid