1548360514 NPI number — DR. PETER GLENN WALLICK M.D.

Table of content: DR. PETER GLENN WALLICK M.D. (NPI 1548360514)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548360514 NPI number — DR. PETER GLENN WALLICK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLICK
Provider First Name:
PETER
Provider Middle Name:
GLENN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1548360514
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2000 SCOTLAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAMBERSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17201-1452
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-263-7788
Provider Business Mailing Address Fax Number:
717-263-7609

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 SCOTLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAMBERSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17201-1452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-263-7788
Provider Business Practice Location Address Fax Number:
717-263-7609
Provider Enumeration Date:
09/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208200000X , with the licence number:  044-299-L , 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: 001253180 0003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001253180 0002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 678804 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 347968700 . This is a "DEPT. OF LABOR (WC)" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: PO00756 . This is a "CHAMPUS-TRICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 01041201 . This is a "BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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