Provider Demographics
NPI:1164688131
Name:FAMILY MEDICINE AT SPRING GROVE LLC
Entity Type:Organization
Organization Name:FAMILY MEDICINE AT SPRING GROVE LLC
Other - Org Name:NANCY A. FAULKNER MD
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN, OWNER OF BUSINESS/LLC
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:FAULKNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:717-739-8174
Mailing Address - Street 1:24 ROTH'S CHURCH ROAD
Mailing Address - Street 2:
Mailing Address - City:SPRING GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17362
Mailing Address - Country:US
Mailing Address - Phone:717-739-8174
Mailing Address - Fax:717-739-8180
Practice Address - Street 1:24 ROTH'S CHURCH ROAD
Practice Address - Street 2:
Practice Address - City:SPRING GROVE
Practice Address - State:PA
Practice Address - Zip Code:17362
Practice Address - Country:US
Practice Address - Phone:717-739-8174
Practice Address - Fax:717-739-8180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-30
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD424789207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty