Basic Information
Provider Information | |||||||||
NPI: | 1669457636 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FOREMAN | ||||||||
FirstName: | THADDEUS | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 129 W HILLSIDE DR | ||||||||
Address2: |   | ||||||||
City: | OXFORD | ||||||||
State: | PA | ||||||||
PostalCode: | 193631126 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7175604200 | ||||||||
FaxNumber: | 7175606380 | ||||||||
Practice Location | |||||||||
Address1: | 231 GRANITE RUN DR | ||||||||
Address2: |   | ||||||||
City: | LANCASTER | ||||||||
State: | PA | ||||||||
PostalCode: | 176016823 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7175604200 | ||||||||
FaxNumber: | 7175606380 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/13/2005 | ||||||||
LastUpdateDate: | 08/27/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA003488L | PA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | MA003488L | 01 | PA | LICENSE | OTHER | P00083341 | 01 |   | RAILROAD MEDICARE | OTHER |