Basic Information
| Provider Information | |||||||||
| NPI: | 1063482172 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUBAKER | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | KENNETH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2110 HARRISBURG PIKE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176043200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175443022 | ||||||||
| FaxNumber: | 7175443021 | ||||||||
| Practice Location | |||||||||
| Address1: | 2110 HARRISBURG PIKE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176043200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175443022 | ||||||||
| FaxNumber: | 7175443021 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 03/30/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | MD012919E | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0006876040002 | 05 | PA | MEDICAID | 127131 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 01350102 | 01 | PA | CAPITAL BLUE CROSS | OTHER | P002665 | 01 | PA | GATEWAY HEALTH PLAN | OTHER | 4662910 | 01 | PA | AETNA NON-HMO | OTHER | 000687604 | 05 | PA | MEDICAID | 20011 S101 | 01 | PA | GEISINGER HEALTH PLAN | OTHER | 0006876040001 | 05 | PA | MEDICAID | 0006876040004 | 05 | PA | MEDICAID | 516348 | 01 | PA | AETNA HMO | OTHER |