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 | | MD046166L | 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 | 01105601 | OTHER | PENNSYLVANIA | CAPITAL BLUE CROSS-WMG ST |
| 2 | 0897774000 | OTHER | PENNSYLVANIA | AMERIHEALTH 65 PA |
| 3 | 80987 | OTHER | PENNSYLVANIA | UNISON-WMG STONY BROOK FM |
| 4 | P002805 | OTHER | PENNSYLVANIA | GATEWAY-WMG |
| 5 | 001573125 | MEDICAID | PENNSYLVANIA | |
| 6 | 1142439 | OTHER | PENNSYLVANIA | AH MERCY-WMG SBFM |
| 7 | 238941 | OTHER | PENNSYLVANIA | MAMSI-WMG STONY BROOK FM |
| 8 | 30082367 | OTHER | PENNSYLVANIA | AMERIHEALTH CARITAS-WOY |
| 9 | 543297 | OTHER | MARYLAND | CAREFIRST MD BCBS |
| 10 | 1567480 | OTHER | PENNSYLVANIA | GATEWAY-WMG WRC |
| 11 | 186101 | OTHER | PENNSYLVANIA | UNISON-WMG READYCARE |
| 12 | 55188 | OTHER | PENNSYLVANIA | GEISINGER |
| 13 | 851600 | OTHER | PENNSYLVANIA | HIGHMARK BLUE SHIELD |
| 14 | 080091005 | MEDICARE PIN | PENNSYLVANIA | |
| 15 | 851600FLT | MEDICARE PIN | PENNSYLVANIA | |
| 16 | 030028 | OTHER | PENNSYLVANIA | JOHNS HOPKINS |
| 17 | 20054651 | OTHER | PENNSYLVANIA | AH MERCY-WMG RC |
| 18 | 2161250 | OTHER | PENNSYLVANIA | MAMSI-WMG READYCARE |
| 19 | 3008236 | OTHER | PENNSYLVANIA | AMERIHEALTH MERCY-WMG |
| 20 | 311914 | OTHER | PENNSYLVANIA | UNISON-WMG |
| 21 | G24193 | MEDICARE UPIN | PENNSYLVANIA | |
| 22 | 1567480 | OTHER | PENNSYLVANIA | GATEWAY-WMG WOY |
| 23 | 50062678 | OTHER | PENNSYLVANIA | CAPITAL BLUE CROSS-WMG RE |
| 24 | 5840126 | OTHER | PENNSYLVANIA | AETNA |