Provider Demographics
NPI:1114926920
Name:SCHRACK, SAMUEL EDWIN (DO)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:EDWIN
Last Name:SCHRACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:MONTOURSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17754-1510
Mailing Address - Country:US
Mailing Address - Phone:570-519-1322
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:217 KING STREET
Practice Address - Street 2:
Practice Address - City:LAPORTE
Practice Address - State:PA
Practice Address - Zip Code:18626-0095
Practice Address - Country:US
Practice Address - Phone:570-946-5101
Practice Address - Fax:570-946-4341
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS007012E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA875448OtherMEDICARE
PA0012632580008Medicaid
PA50009421OtherCAPITAL BC
PA74745OtherGEISINGER HEALTH PLAN
PA001726OtherFIRST PRIORITY HEALTH
PASC648398OtherBLUE SHIELD
PASC648398OtherBLUE SHIELD
PA0012632580004Medicaid