1114927043 NPI number — AGAPE FAMILY MEDICINE, PC

Table of content: (NPI 1114927043)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114927043 NPI number — AGAPE FAMILY MEDICINE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AGAPE FAMILY MEDICINE, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114927043
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
410 CUMBERLAND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEBANON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17042-5351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-270-0335
Provider Business Mailing Address Fax Number:
717-270-9740

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
410 CUMBERLAND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17042-5351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-270-0335
Provider Business Practice Location Address Fax Number:
717-270-9740
Provider Enumeration Date:
07/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LONG
Authorized Official First Name:
REBECCA
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
717-270-0335

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD-064156L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5130980 . This is a "HEALTHGUARD" identifier . This identifiers is of the category "OTHER".
  • Identifier: L019072 . This is a "BLUE CROSS/BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01711849 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 129891 . This is a "HEALTH AMERICA/ASSURANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1684763 . This is a "HIGHMARK BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 85419 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01391101 . This is a "CAPITAL BLUE CROSS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 15097 . This is a "GEISINGER HEALTH PLAN" identifier . This identifiers is of the category "OTHER".




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