Provider Demographics
NPI:1235125139
Name:QUANTUM PET LP
Entity type:Organization
Organization Name:QUANTUM PET LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING EMPLOYER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:BERGEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:717-938-2765
Mailing Address - Street 1:629D LOWTHER RD
Mailing Address - Street 2:
Mailing Address - City:LEWISBERRY
Mailing Address - State:PA
Mailing Address - Zip Code:17339-9527
Mailing Address - Country:US
Mailing Address - Phone:877-554-2738
Mailing Address - Fax:717-932-2430
Practice Address - Street 1:629D LOWTHER RD
Practice Address - Street 2:
Practice Address - City:LEWISBERRY
Practice Address - State:PA
Practice Address - Zip Code:17339-9527
Practice Address - Country:US
Practice Address - Phone:877-554-2738
Practice Address - Fax:717-932-2430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-26
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PANONE2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001961930Medicaid
PA040635Medicare ID - Type Unspecified
PA001961930Medicaid