Basic Information
| Provider Information | |||||||||
| NPI: | 1477532653 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANNVILLE FAMILY MEDICINE, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 475 N WEABER ST | ||||||||
| Address2: | |||||||||
| City: | ANNVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170031104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178674671 | ||||||||
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| Practice Location | |||||||||
| Address1: | 475 N WEABER ST | ||||||||
| Address2: | |||||||||
| City: | ANNVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170031104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178674671 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2006 | ||||||||
| LastUpdateDate: | 12/03/2009 | ||||||||
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| AuthorizedOfficialLastName: | NICKLISS | ||||||||
| AuthorizedOfficialFirstName: | VELMA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7178674671 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100935901 | 05 | PA | MEDICAID |