MEDICARE: FAYETTE PHYSICIAN NETWORK INC

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1710389994
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAYETTE PHYSICIAN NETWORK INC

Provider Business Mailing Address
First Line	:	111B ROBERTS RD
Second Line	:
City	:	GRINDSTONE
State	:	PA
Zip	:	15442-1105
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	111B ROBERTS RD
Second Line	:
City	:	GRINDSTONE
State	:	PA
Zip	:	15442-1105
Country	:	US
Telephone Number	:	724-785-2286
Fax Number	:	724-785-3187

Authorized Official
Title or Position	:	SR.DIRECTOR
Name	:	MARK EHALT
Credential	:
Telephone Number	:	412-647-0943

Provider Enumeration Date	:	09/19/2014
Last Update Date	:	09/19/2014

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