Basic Information
| Provider Information | |||||||||
| NPI: | 1114036084 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FATULA | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 E MAIN ST | ||||||||
| Address2: | P O BOX 189 | ||||||||
| City: | REYNOLDSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158511282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143711510 | ||||||||
| FaxNumber: | 8143712922 | ||||||||
| Practice Location | |||||||||
| Address1: | 529 SUNFLOWER DR | ||||||||
| Address2: | |||||||||
| City: | DU BOIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158012378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143711510 | ||||||||
| FaxNumber: | 8143712922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 06/16/2011 | ||||||||
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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 | 208000000X | MD013412-E | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000649078 | 05 | PA | MEDICAID |