Basic Information
| Provider Information | |||||||||
| NPI: | 1326081704 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STURDEVANT | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 641057 | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152641057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006552656 | ||||||||
| FaxNumber: | 4128227411 | ||||||||
| Practice Location | |||||||||
| Address1: | 515 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OLEAN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147601513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163732600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 10/10/2012 | ||||||||
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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 | 207R00000X | MD428120 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1552882 | 01 | PA | GATEWAY | OTHER | 411353 | 01 | PA | UPMC | OTHER | 1015984860001 | 05 | PA | MEDICAID | 2655247 | 01 | OH | OH MEDICAL ASSISTANCE | OTHER | P00339483 | 01 | PA | RR MEDICARE | OTHER | 1861235 | 01 | PA | BLUE SHIELD | OTHER | 00027610101 | 01 | PA | UNIVERA | OTHER | 1069667 | 01 | WV | W. VIRGINIA WORKERS COMP | OTHER | 02757308 | 01 | NY | NY MEDICAL ASSISTANCE | OTHER | 1333544 | 01 | PA | AETNA | OTHER | 186463 | 01 | PA | UNISON | OTHER |