Healthcare Provider Details

I. General information

NPI: 1114927043
Provider Name (Legal Business Name): AGAPE FAMILY MEDICINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 CUMBERLAND ST
LEBANON PA
17042-5351
US

IV. Provider business mailing address

410 CUMBERLAND ST
LEBANON PA
17042-5351
US

V. Phone/Fax

Practice location:
  • Phone: 717-270-0335
  • Fax: 717-270-9740
Mailing address:
  • Phone: 717-270-0335
  • Fax: 717-270-9740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD-064156L
License Number StatePA

VIII. Authorized Official

Name: REBECCA R LONG
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 717-270-0335