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 | 207Q00000X | Family Medicine | | MD042647L | 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 | 001468 | OTHER | | FIRST PRIORITY HEALTH HMO |
| 2 | 080070777 | OTHER | | RAILROADMEDICARE |
| 3 | 0012220210002 | MEDICAID | PENNSYLVANIA | |
| 4 | 0461081000 | OTHER | | PABLUE CROSS |
| 5 | E59863 | MEDICARE UPIN | | |
| 6 | B0631143 | MEDICARE ID-TYPE UNSPECIFIED | PENNSYLVANIA | |
| 7 | 001290633 | OTHER | | UNITED |
| 8 | 631143 | OTHER | | PA BLUE SHIELD |
| 9 | 0461081000 | OTHER | | BPC |
| 10 | 27539 E475 | OTHER | | GEISINGER HEALTH/990LD 9H |
| 11 | 2Y2168 | OTHER | | HEALTH AMERICA |
| 12 | 631143 | MEDICARE PIN | PENNSYLVANIA | |
| 13 | 631143 | OTHER | | FIRST PRIORITY LIFE |
| 14 | 27539 E475 | OTHER | | GGOLD |
| 15 | 27539 E475 | OTHER | | GHP |
| 16 | E59863 | OTHER | | STERLING |
| 17 | 536762 | OTHER | | AETNA |
