Healthcare Provider Details

I. General information

NPI: 1396715389
Provider Name (Legal Business Name): SLATE BELT FAMILY PRACTICE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 S BROADWAY
WIND GAP PA
18091-1628
US

IV. Provider business mailing address

826 S BROADWAY
WIND GAP PA
18091-1628
US

V. Phone/Fax

Practice location:
  • Phone: 610-863-3019
  • Fax: 610-863-6732
Mailing address:
  • Phone: 610-863-3019
  • Fax: 610-863-6732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS-006844L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS-007427L
License Number StatePA

VIII. Authorized Official

Name: DR. WAYNE J BROTZMAN JR.
Title or Position: PHYSICIAN
Credential: D.O.
Phone: 610-863-3019