Healthcare Provider Details

I. General information

NPI: 1841098589
Provider Name (Legal Business Name): MEDICAL PRACTICES OF ANTIETAM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2025
Last Update Date: 03/07/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 ST PAUL DR
CHAMBERSBURG PA
17201-1020
US

IV. Provider business mailing address

11116 MEDICAL CAMPUS RD
HAGERSTOWN MD
21742-6710
US

V. Phone/Fax

Practice location:
  • Phone: 717-261-1620
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA REPAC
Title or Position: CFO
Credential:
Phone: 301-790-9351