Basic Information
| Provider Information | |||||||||
| NPI: | 1588613186 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHIKELLAMY EMERGENCY PHYSICIANS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 232 LAKESIDE DR | ||||||||
| Address2: | |||||||||
| City: | HORSHAM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190442319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002478060 | ||||||||
| FaxNumber: | 2159572875 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 N 11TH ST | ||||||||
| Address2: | |||||||||
| City: | SUNBURY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178011611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702863333 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/GENERAL PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8002478060 | ||||||||
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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 | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 50039389 | 01 | PA | BLUE CROSS | OTHER | 1010867190001 | 05 | PA | MEDICAID | SH1626131 | 01 | PA | BLUE SHIELD | OTHER |