Provider Demographics
NPI:1871592055
Name:MEDICAL PARK EAR NOSE & THROAT LTD
Entity type:Organization
Organization Name:MEDICAL PARK EAR NOSE & THROAT LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-523-1163
Mailing Address - Street 1:80 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837-6343
Mailing Address - Country:US
Mailing Address - Phone:570-523-1163
Mailing Address - Fax:570-524-5737
Practice Address - Street 1:80 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837-6343
Practice Address - Country:US
Practice Address - Phone:570-523-1163
Practice Address - Fax:570-524-5737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD023535E207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007486870002Medicaid
PA01650001OtherCAPITAL BLUE CROSS
PA072467OtherMEDICARE PTAN
PA01650001OtherCAPITAL BLUE CROSS