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 | | MD029417E | PENNSYLVANIA | No |
| 2 | 207Q00000X | Family Medicine | | 2012-01246 | NORTH CAROLINA | 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 | 50068269 | OTHER | PENNSYLVANIA | CAPITAL BLUE CROSS |
| 2 | 117199G21 | MEDICARE PIN | PENNSYLVANIA | |
| 3 | 01584601 | OTHER | PENNSYLVANIA | CAPITAL BLUE CROSS |
| 4 | B37026 | MEDICARE UPIN | PENNSYLVANIA | |
| 5 | 50041795 | OTHER | PENNSYLVANIA | CAPITAL BLUE CROSS |
| 6 | 50060208 | OTHER | PENNSYLVANIA | CAPITAL BLUE CROSS |
| 7 | 50061979 | OTHER | PENNSYLVANIA | CAPITAL BLUE CROSS |
| 8 | B37026 | OTHER | PENNSYLVANIA | HEALTH ASSURANCE |
| 9 | 12233 S1QI | OTHER | PENNSYLVANIA | GEISINGER HEALTH PLAN |
| 10 | 50043858 | OTHER | PENNSYLVANIA | CAPITAL BLUE CROSS |
| 11 | 533036 | OTHER | PENNSYLVANIA | AETNA HMO |
| 12 | 0009985890001 | MEDICAID | PENNSYLVANIA | |
| 13 | 080084966 | OTHER | PENNSYLVANIA | RAILROAD MEDICARE |
| 14 | 50046249 | OTHER | PENNSYLVANIA | CAPITAL BLUE CROSS |
| 15 | 117199JZE | MEDICARE PIN | PENNSYLVANIA | |
| 16 | 4527767 | OTHER | PENNSYLVANIA | AETNA NON-HMO |
| 17 | P002648 | OTHER | PENNSYLVANIA | GATEWAY HEALTH PLAN |
| 18 | 117199 | OTHER | PENNSYLVANIA | HIGHMARK BLUE SHIELD |
