Healthcare Provider Details

I. General information

NPI: 1821067901
Provider Name (Legal Business Name): MARILYN F WITHERUP MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 E 16TH ST
BERWICK PA
18603-2316
US

IV. Provider business mailing address

137 DEEP DRIFT DR
BLOOMSBURG PA
17815-6805
US

V. Phone/Fax

Practice location:
  • Phone: 570-759-5250
  • Fax: 570-759-5522
Mailing address:
  • Phone: 570-784-6820
  • Fax: 570-784-6820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberMD012835E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier001086289
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: