MEDICARE: MR. GEORGE M PROTENIC

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	363A00000X	Physician Assistant	MA000658L	PA
2	363AM0700X	Medical Physician Assistant	MA0006581	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932172335
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GEORGE M PROTENIC

Provider Business Mailing Address
First Line	:	207 N BROAD ST FL 3
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-1500
Country	:	US
Telephone Number	:	267-479-4142
Fax Number	:

Provider Business Practice Location Address
First Line	:	826 MAIN ST STE 100
Second Line	:
City	:	PHOENIXVILLE
State	:	PA
Zip	:	19460-4459
Country	:	US
Telephone Number	:	484-928-6780
Fax Number	:	267-741-0003

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

Provider Enumeration Date	:	02/08/2006
Last Update Date	:	07/15/2021

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Directions to “ MR. GEORGE M PROTENIC ” Practice Location

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