Provider Demographics
NPI:1245221506
Name:FOGARTY, KEVIN T (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:T
Last Name:FOGARTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5325 NORTHGATE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18017-9411
Mailing Address - Country:US
Mailing Address - Phone:610-691-8931
Mailing Address - Fax:610-691-8947
Practice Address - Street 1:300 LACKAWANNA AVE STE 200
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18503-2001
Practice Address - Country:US
Practice Address - Phone:484-884-4500
Practice Address - Fax:570-800-7529
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD044115L2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAF23176Medicare UPIN
PA718311Medicare ID - Type Unspecified