Provider Demographics
NPI:1275586281
Name:KENNETH R DURRWACHTER MD PC
Entity Type:Organization
Organization Name:KENNETH R DURRWACHTER MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:R
Authorized Official - Last Name:DURRWACHTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-601-6230
Mailing Address - Street 1:1705 WARREN AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-2647
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1705 WARREN AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-2647
Practice Address - Country:US
Practice Address - Phone:570-601-6230
Practice Address - Fax:570-601-6232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD045039L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1016212250001Medicaid
PAC253OtherGEISINGER HEALTH PLAN
PA1849658OtherHIGHMARK BLUE SHIELD
PA222566OtherFIRST PRIORITY HEALTH
PAC253OtherGEISINGER HEALTH PLAN
PADE9146Medicare PIN