MEDICARE: MOLLY ETTENGER M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	MD033641E	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ET479017	OTHER	PA	HIGHMARK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	67407	OTHER	PA	GEISSINGER

General Provider Information

NPI Number	:	1326044421
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOLLY ETTENGER M.D.

Provider Business Mailing Address
First Line	:	1225 WARM SPRINGS AVE
Second Line	:
City	:	HUNTINGDON
State	:	PA
Zip	:	16652-2350
Country	:	US
Telephone Number	:	814-643-2290
Fax Number	:	814-643-8334

Provider Business Practice Location Address
First Line	:	900 BRYAN ST
Second Line	:
City	:	HUNTINGDON
State	:	PA
Zip	:	16652-2413
Country	:	US
Telephone Number	:	814-643-8300
Fax Number	:	814-643-8299

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	04/01/2011

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