Basic Information
| Provider Information | |||||||||
| NPI: | 1982686226 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRAL PENN GASTROENTEROLOGY ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178379419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705242722 | ||||||||
| FaxNumber: | 5705240362 | ||||||||
| Practice Location | |||||||||
| Address1: | 90 MEDICAL PARK DRIVE | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178379419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705242722 | ||||||||
| FaxNumber: | 5705240362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PETORAK | ||||||||
| AuthorizedOfficialFirstName: | VLADIMIR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5705242722 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0018133010005 | 05 | PA | MEDICAID |