MEDICARE: PAUL A KETTL M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	MD036495E	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	50048776	OTHER	PA	CAPITAL BLUE CROSS
2	100774	OTHER	PA	VALUE OPTIONS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	427936	OTHER	PA	HIGHMARK BLUE SHIELD
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124018254
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL A KETTL M.D.

Provider Business Mailing Address
First Line	:	802 NEW HOLLAND AVE
Second Line	:
City	:	LANCASTER
State	:	PA
Zip	:	17602-2163
Country	:	US
Telephone Number	:	717-560-3782
Fax Number	:	717-560-3787

Provider Business Practice Location Address
First Line	:	802 NEW HOLLAND AVE
Second Line	:
City	:	LANCASTER
State	:	PA
Zip	:	17602-2163
Country	:	US
Telephone Number	:	717-560-3782
Fax Number	:	717-560-3787

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/28/2005
Last Update Date	:	08/19/2007

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