Basic Information
| Provider Information | |||||||||
| NPI: | 1689627648 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PENN NEUROLOGIC ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 920 LAWN AVE | ||||||||
| Address2: | THE SUMMIT | ||||||||
| City: | SELLERSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 189601560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152574900 | ||||||||
| FaxNumber: | 2152576681 | ||||||||
| Practice Location | |||||||||
| Address1: | 920 LAWN AVE | ||||||||
| Address2: | THE SUMMIT | ||||||||
| City: | SELLERSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 189601560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152574900 | ||||||||
| FaxNumber: | 2152576681 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 10/05/2015 | ||||||||
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| AuthorizedOfficialLastName: | BUCKLER | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | ALAN | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 2152574900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | MD040916E | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 03195000 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 0085270 | 01 | PA | CIGNA | OTHER | 1001358 | 01 | PA | KEYSTONE MERCY | OTHER | 5740334 | 01 | PA | AETNA COMERCIAL | OTHER | 0055941 | 01 | PA | US HEALTHCARE | OTHER | 0012941560002 | 05 | PA | MEDICAID | 0022227000 | 01 | PA | KEYSTONE HEALTH PLAN EAST | OTHER |