Basic Information
| Provider Information | |||||||||
| NPI: | 1164536405 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EPHRATA RADIOLOGIC ASSOCIATES LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 MERIDIAN BLVD | ||||||||
| Address2: | 2ND FLR | ||||||||
| City: | WYOMISSING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 196103202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103724957 | ||||||||
| FaxNumber: | 6102880173 | ||||||||
| Practice Location | |||||||||
| Address1: | 169 MARTIN AVE | ||||||||
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| City: | EPHRATA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 175221724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177386137 | ||||||||
| FaxNumber: | 7178594475 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 10/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | BROSBE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | HEAD PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 7177386137 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0009042050010 | 05 | PA | MEDICAID |