Basic Information
| Provider Information | |||||||||
| NPI: | 1184643488 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUGLAS | ||||||||
| FirstName: | RAY | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 HOSPITAL DR STE 306 | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178379350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705224110 | ||||||||
| FaxNumber: | 5707683911 | ||||||||
| Practice Location | |||||||||
| Address1: | 964 CARPENTER RD | ||||||||
| Address2: | |||||||||
| City: | MILTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178477527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5707422300 | ||||||||
| FaxNumber: | 5707426276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 05/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD059568L | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 881703 | 01 | PA | BLUE SHIELD | OTHER | 14953C3AB | 01 | PA | GEISINGER | OTHER | 50044499 | 01 | PA | BLUE CROSS | OTHER | 50044499 | 01 | PA | KEYSTONE | OTHER | G44887 | 01 | PA | HEALTH AMERICA | OTHER | 080113566 | 01 | PA | RAILROAD MEDICARE | OTHER | 0015759160011 | 05 | PA | MEDICAID | 232809429 | 01 | PA | TRICARE | OTHER |