Healthcare Provider Details

I. General information

NPI: 1710389994
Provider Name (Legal Business Name): FAYETTE PHYSICIAN NETWORK INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2014
Last Update Date: 09/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111B ROBERTS RD
GRINDSTONE PA
15442-1105
US

IV. Provider business mailing address

111B ROBERTS RD
GRINDSTONE PA
15442-1105
US

V. Phone/Fax

Practice location:
  • Phone: 724-785-2286
  • Fax: 724-785-3187
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MARK EHALT
Title or Position: SR.DIRECTOR
Credential:
Phone: 412-647-0943