Provider Demographics
NPI:1043280969
Name:ECKENRODE, GEORGE T (CNM)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:T
Last Name:ECKENRODE
Suffix:
Gender:M
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 S 2ND ST STE 2F
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1575 HIGHLANDS DR
Practice Address - Street 2:SUITE 101
Practice Address - City:LITITZ
Practice Address - State:PA
Practice Address - Zip Code:17543-7507
Practice Address - Country:US
Practice Address - Phone:717-393-1338
Practice Address - Fax:717-627-1817
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMW008165L367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001442535Medicaid
PAS22160Medicare UPIN
PA001442535Medicaid