Provider Demographics
NPI:1093995938
Name:ROY W GERNHARDT III MD PC
Entity Type:Organization
Organization Name:ROY W GERNHARDT III MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:W
Authorized Official - Last Name:GERNHARDT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-288-6888
Mailing Address - Street 1:415 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-4411
Mailing Address - Country:US
Mailing Address - Phone:570-208-5571
Mailing Address - Fax:570-208-5548
Practice Address - Street 1:1732 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:FORTY FORT
Practice Address - State:PA
Practice Address - Zip Code:18704-4340
Practice Address - Country:US
Practice Address - Phone:570-288-6888
Practice Address - Fax:570-288-6880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD432211207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA117752Medicare PIN