Provider Demographics
NPI:1063634863
Name:EISENHUTH, KATHRYN K (MD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:K
Last Name:EISENHUTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:
Practice Address - Street 1:132 ABIGAIL LN
Practice Address - Street 2:
Practice Address - City:PORT MATILDA
Practice Address - State:PA
Practice Address - Zip Code:16870
Practice Address - Country:US
Practice Address - Phone:814-272-7100
Practice Address - Fax:814-272-6501
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101245316208000000X
MS21219208000000X
PAMD462276208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09463OtherGROUP PTAN
MS07585750Medicaid
MS302I376595Medicare PIN