NPIMap

Individual provider Active NPI

Edgar Bonchita Gantalao, M.D.

  • Psychiatry Physician
  • Du Bois, PA
National Provider Identifier
1649200411
Registry record updated Sep 6, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
License
MD418498 Issued in PA
Practice address
635 Maple Ave
Du Bois, PA 15801-2376
Phone
(814) 375-6379
Fax
(814) 375-9320
NPI assigned
Jul 4, 2006
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Sep 6, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatry Physician 2084P0800X MD418498 PA Primary

Addresses

Primary practice location

635 Maple Ave
Du Bois, PA 15801-2376

Mailing address

100 Hospital Ave
Du Bois, PA 15801-1440
Phone (814) 375-6379

Other identifiers 2

IdentifierTypeStateIssuer
0019070610006MedicaidPA
001424280OtherPAHIGHMARK BC/BS

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20101012001333 PA Practitioner - Psychiatry 9638361355 Reassigns benefits to 4 organizations

Care Compare profile

Medicare Care Compare
Specialty
Psychiatry
Education
Other, 1980
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Dubois Regional Medical Center 424 clinicians

Practice addresses (Care Compare)

635 Maple Ave
DRMC Behaviorial HLTH
Dubois, PA 15801-2383
Phone (814) 375-6379

Hospital & facility affiliations

  • Penn Highlands Dubois Hospital, Dubois, PA, CCN 390086

Merit-based Incentive Payment System (MIPS)

Final score
96.6 of 100Reported as group
Promoting interoperability
96
Improvement activities
40

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
MD418498PAMDPsychiatry Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Brookville Hospital CurrentSince Aug 1, 2012 Accepting new patients
Brookville Hospital CurrentSince Dec 1, 2025 Accepting new patients
Dubois Regional Medical Center CurrentSince Jun 1, 2002 Accepting new patients
Elk Regional Health Center Psychiatry CurrentSince Feb 1, 2015 Accepting new patients
Brookville Hospital CurrentSince Aug 1, 2012 Accepting new patients
Elk Regional Health Center CurrentSince Feb 1, 2015 Accepting new patients
Dubois Regional Medical Center Psychiatry CurrentSince Jun 1, 2002 Accepting new patients
Dubois Regional Medical Center Past Accepting new patients
Clearfield Hospital Past Accepting new patients
Clearfield Hospital Past Accepting new patients

Locations

100 Hospital Rd
Brookville, PA 15825
Phone (814) 849-1408

1033 Turnpike Ave
Ste 100
Clearfield, PA 16830
Phone (814) 765-7585

809 Turnpike Ave
Clearfield, PA 16830
Phone (814) 765-5341

820 Turnpike Ave
Clearfield, PA 16830
Phone (814) 765-2006

1033 Turnpike Ave
Ste 300
Clearfield, PA 16830
Phone (814) 768-2137

531 Hannah St
Ste A
Clearfield, PA 16830
Phone (814) 765-0375

100 Caldwell Dr
Dubois, PA 15801

90 Beaver Dr
Ste 121D
Dubois, PA 15801
Phone (814) 371-3323

100 Hospital Ave
Dubois, PA 15801
Phone (814) 375-2040

275 E 4th St
Emporium, PA 15834
Phone (814) 486-6123

111 Cobb St
Johnsonburg, PA 15845
Phone (814) 965-2857

763 Johnsonburg Rd
Saint Marys, PA 15857
Phone (814) 788-8000

Interoperability endpoints

  • Direct secure messaging: ebgantalao@1285.direct.myezyaccess.com

Organizations & group practices 10

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 28

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 28

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1151971200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1346889600000",
    "number": "1649200411",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 HOSPITAL AVE",
            "city": "DU BOIS",
            "state": "PA",
            "postal_code": "158011440",
            "telephone_number": "814-375-6379",
            "fax_number": "814-375-9320"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "635 MAPLE AVE",
            "city": "DU BOIS",
            "state": "PA",
            "postal_code": "158012376",
            "telephone_number": "814-375-6379",
            "fax_number": "814-375-9320"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "GANTALAO",
        "first_name": "EDGAR",
        "middle_name": "BONCHITA",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-07-04",
        "last_updated": "2012-09-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "PA",
            "license": "MD418498",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0019070610006",
            "state": "PA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HIGHMARK BC/BS",
            "identifier": "001424280",
            "state": "PA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Du Bois, PA

Sources for this page

Verify at the official NPI Registry.