Provider Demographics
NPI:1285669341
Name:FOGARTY, BRIAN KIRBY (MED)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:KIRBY
Last Name:FOGARTY
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:352 FUTURITY DR
Mailing Address - Street 2:
Mailing Address - City:CAMP HILL
Mailing Address - State:PA
Mailing Address - Zip Code:17011
Mailing Address - Country:US
Mailing Address - Phone:717-774-1218
Mailing Address - Fax:
Practice Address - Street 1:426 S THIRD ST
Practice Address - Street 2:STE 201
Practice Address - City:LEMOYNE
Practice Address - State:PA
Practice Address - Zip Code:17043
Practice Address - Country:US
Practice Address - Phone:717-737-2448
Practice Address - Fax:717-774-1435
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS004024L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAF0144575OtherHIGHMARK BLUE SHIELD
PA01633901OtherCAPITAL BLUE CROSS