Provider Demographics
NPI:1447235767
Name:MODRAK, ROBERT THOMAS (PA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:THOMAS
Last Name:MODRAK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UNIVERSITY DRIVE C
Mailing Address - Street 2:VA PITTSBURGH HEALTHCARE SYSTEM
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15240
Mailing Address - Country:US
Mailing Address - Phone:412-688-6603
Mailing Address - Fax:412-232-7351
Practice Address - Street 1:1350 LOCUST ST
Practice Address - Street 2:MERCY ORTHOPEDIC ASSICIATES SUITE220
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15219-4738
Practice Address - Country:US
Practice Address - Phone:412-232-5800
Practice Address - Fax:412-232-7351
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA002121363A00000X
PAMA000496L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA507669Medicare UPIN
PA075804RZRMedicare ID - Type Unspecified
PA075804E0DMedicare PIN