Provider Demographics
NPI:1447243738
Name:WYNTRE BROOK SURGICAL ASSOCIATES, PC
Entity type:Organization
Organization Name:WYNTRE BROOK SURGICAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/ACTIVE,ATTENDING
Authorized Official - Prefix:
Authorized Official - First Name:NIKHILESH
Authorized Official - Middle Name:
Authorized Official - Last Name:AGARWAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:717-812-2921
Mailing Address - Street 1:1399 S QUEEN ST
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17403-3840
Mailing Address - Country:US
Mailing Address - Phone:717-812-2921
Mailing Address - Fax:717-812-2921
Practice Address - Street 1:1399 S QUEEN ST
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-3840
Practice Address - Country:US
Practice Address - Phone:717-812-2921
Practice Address - Fax:717-812-2921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD024908E2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012711600001Medicaid
PA0012711600001Medicaid