Healthcare Provider Details

I. General information

NPI: 1497702104
Provider Name (Legal Business Name): ALLEN BELO ETTENGER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 07/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1227 WARM SPRINGS AVE J. C. BLAIR MEDICAL BUILDING, STE. 301
HUNTINGDON PA
16652-2300
US

IV. Provider business mailing address

1227 WARM SPRINGS AVE STE. 301
HUNTINGDON PA
16652-2300
US

V. Phone/Fax

Practice location:
  • Phone: 814-643-8574
  • Fax: 814-643-8659
Mailing address:
  • Phone: 814-643-8574
  • Fax: 814-643-8659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberMD033218
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier0010017640005
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: