=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114559150
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ADAM HARBAUGH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2020
-----------------------------------------------------
Last Update Date | 02/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 PROSPECT ST
-----------------------------------------------------
City | EAST STROUDSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18301-2956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-422-3211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 142 MEYERS ST
-----------------------------------------------------
City | EDWARDSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18704-2610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-852-9848
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------