Basic Information
Provider Information | |||||||||
NPI: | 1124498746 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PAIN MEDICINE OF YORK, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1497A S. QUEEN STREET | ||||||||
Address2: |   | ||||||||
City: | YORK | ||||||||
State: | PA | ||||||||
PostalCode: | 17403 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7178483979 | ||||||||
FaxNumber: | 7176688967 | ||||||||
Practice Location | |||||||||
Address1: | 418 N LOGAN BLVD | ||||||||
Address2: |   | ||||||||
City: | BURNHAM | ||||||||
State: | PA | ||||||||
PostalCode: | 170091816 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7178483979 | ||||||||
FaxNumber: | 7176688967 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/25/2015 | ||||||||
LastUpdateDate: | 02/28/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | YENTZER | ||||||||
AuthorizedOfficialFirstName: | RODNEY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO/OWNER | ||||||||
AuthorizedOfficialTelephone: | 7172261665 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 207LP2900X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.