MEDICARE: MR. LARRY D BARTHOLOMEW PA-C

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	MA000051L	PA

General Provider Information

NPI Number	:	1942353289
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LARRY D BARTHOLOMEW PA-C

Provider Business Mailing Address
First Line	:	30 TYLER DR
Second Line	:
City	:	PINE GROVE
State	:	PA
Zip	:	17963-8050
Country	:	US
Telephone Number	:	717-861-9175
Fax Number	:	717-861-8235

Provider Business Practice Location Address
First Line	:	30 TYLER DR
Second Line	:
City	:	PINE GROVE
State	:	PA
Zip	:	17963-8050
Country	:	US
Telephone Number	:	570-345-3254
Fax Number	:

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

Provider Enumeration Date	:	01/19/2007
Last Update Date	:	07/08/2007

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