Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 207R00000X | Internal Medicine | | MD017380E | PENNSYLVANIA | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 4708888939 | OTHER | | CCN |
| 2 | 0006355640003 | MEDICAID | PENNSYLVANIA | |
| 3 | 0001435061 | OTHER | | PENNSYLVANIA BLUE SHIELD |
| 4 | 007302 | OTHER | | AETNA PPO |
| 5 | 1058232 | OTHER | | KEYSTONE MERCY HEALTHPLAN |
| 6 | 4708888939 | OTHER | | FIRST HEALTH |
| 7 | 2119896001 | OTHER | | AMERIHEALTH ADMINISTRATOR |
| 8 | 103640 | MEDICARE PIN | PENNSYLVANIA | |
| 9 | 007302 | OTHER | | AETNA |
| 10 | C30087 | MEDICARE UPIN | | |
| 11 | 0001435061 | OTHER | | PERSONAL CHOICE |
| 12 | 470888939 | OTHER | | INTERCOUNTY |
| 13 | 007302 | OTHER | | MANAGED CARE |
| 14 | 21198960001 | OTHER | | KEYSTONE LIAISON |
| 15 | PC0140 | OTHER | | HEALTH NET |
| 16 | 4708888939 | OTHER | | DEVON |
| 17 | 21198960001 | OTHER | | KEYSTONE HEALTH PLAN EAST |
| 18 | 21198960001 | OTHER | | KEYSTONE HLTHPLAN EAST 65 |
| 19 | 2119896001 | OTHER | | AMERIHEALTH HMO |
| 20 | 103640Q3D | MEDICARE ID-TYPE UNSPECIFIED | PENNSYLVANIA | |
| 21 | 000635564 | MEDICAID | PENNSYLVANIA | |
| 22 | 0001435061 | OTHER | | PERSONAL CHOICE 65 |
