Basic Information
| Provider Information | |||||||||
| NPI: | 1770569147 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHERRY TREE PHYSICIAN ASSOCIATES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020A E BOAL AVE | ||||||||
| Address2: | |||||||||
| City: | BOALSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168271509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142378627 | ||||||||
| FaxNumber: | 8142380083 | ||||||||
| Practice Location | |||||||||
| Address1: | 773 CHERRY TREE CT | ||||||||
| Address2: | |||||||||
| City: | HANOVER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173317902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177418100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | KLEYHAUER | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7177418100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 122452 | 01 | PA | THREE RIVERS HEALTH PLAN | OTHER | 1525714 | 01 | PA | GATEWAY | OTHER | 0017303250002 | 05 | PA | MEDICAID | 2586800 | 01 | PA | CAPITAL BC | OTHER | 263000 | 01 | PA | MAMSI | OTHER | 383789 | 01 | PA | BCBS HIGHMARK | OTHER | 993971 | 01 | PA | KEYSTONE HPC | OTHER |