Healthcare Provider Details

I. General information

NPI: 1235125139
Provider Name (Legal Business Name): QUANTUM PET LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 04/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

629D LOWTHER RD
LEWISBERRY PA
17339-9527
US

IV. Provider business mailing address

629D LOWTHER RD
LEWISBERRY PA
17339-9527
US

V. Phone/Fax

Practice location:
  • Phone: 877-554-2738
  • Fax: 717-932-2430
Mailing address:
  • Phone: 877-554-2738
  • Fax: 717-932-2430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberNONE
License Number StatePA

VIII. Authorized Official

Name: ELIZABETH A BERGEY
Title or Position: MANAGING EMPLOYER
Credential: MD
Phone: 717-938-2765