=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275586281
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENNETH R DURRWACHTER MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2006
-----------------------------------------------------
Last Update Date | 01/13/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1705 WARREN AVE SUITE 208
-----------------------------------------------------
City | WILLIAMSPORT
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17701-2647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-601-6230
-----------------------------------------------------
Fax | 570-601-6232
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1705 WARREN AVE SUITE 208
-----------------------------------------------------
City | WILLIAMSPORT
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17701-2647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KENNETH R DURRWACHTER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 570-601-6230
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD045039L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------