Basic Information
| Provider Information | |||||||||
| NPI: | 1730159997 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BROOKPARK FAMILY PRACTICE, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 98 REITZ BLVD | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178379206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705244443 | ||||||||
| FaxNumber: | 5705231855 | ||||||||
| Practice Location | |||||||||
| Address1: | 98 REITZ BLVD | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178379206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705244443 | ||||||||
| FaxNumber: | 5705231855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5705244443 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0352417 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 0018452610001 | 05 | PA | MEDICAID | 139549 | 01 | PA | HEALTH ASSURANCE/AMERICA | OTHER | 02602900 | 01 | PA | CAPITAL BLUE CROSS | OTHER |