Healthcare Provider Details

I. General information

NPI: 1790760072
Provider Name (Legal Business Name): NORMAN NOWAK BIRCHER PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2480 LLEWELLYN AVE ATTN: MCXR-CR . KIMBROUGH AMBULATORY CARE CENTER
FT MEADE MD
20755-5800
US

IV. Provider business mailing address

5461 NURSERY RD
DOVER PA
17315-2335
US

V. Phone/Fax

Practice location:
  • Phone: 301-677-8270
  • Fax: 301-677-8176
Mailing address:
  • Phone: 717-292-9720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA002196L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: