Provider Demographics
NPI:1073610432
Name:G L PAGENKOPF CO PA
Entity Type:Organization
Organization Name:G L PAGENKOPF CO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:PAGENKOPF
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:814-922-3800
Mailing Address - Street 1:181 LEITH WALK EXT
Mailing Address - Street 2:
Mailing Address - City:CONNAUT
Mailing Address - State:OH
Mailing Address - Zip Code:44030
Mailing Address - Country:US
Mailing Address - Phone:440-593-2078
Mailing Address - Fax:
Practice Address - Street 1:14603 RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:PA
Practice Address - Zip Code:16443
Practice Address - Country:US
Practice Address - Phone:814-922-3800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC002428L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0008625260001Medicaid
PA0662096OtherAETNA
PA1500250Medicaid
PA714797OtherHIGHMARK
PA104767OtherHIGHMARK
PA4644065OtherAETNA
PA153721Medicaid
PA6667738OtherCIGNA
OH0492293Medicaid
PA210837OtherUPMC
PA153721Medicaid
PAT30724Medicare UPIN