1346386992 NPI number — RUSSEL H. ETTER MD

Table of content: (NPI 1346386992)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346386992 NPI number — RUSSEL H. ETTER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RUSSEL H. ETTER MD
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:
1346386992
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 WYNTRE BROOKE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YORK
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17403-4536
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-741-3896
Provider Business Mailing Address Fax Number:
717-741-5434

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 WYNTRE BROOKE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YORK
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17403-4536
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-741-3896
Provider Business Practice Location Address Fax Number:
717-741-5434
Provider Enumeration Date:
01/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WOLFGANG
Authorized Official First Name:
PAMELA
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
717-741-3896

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  MD008050E , 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: 03206000 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 172355 . This is a "HEALTHAMERICAN PA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0004626999 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 8110175 . This is a "CIGNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 000018534 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0643575 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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