Provider Demographics
NPI:1306000245
Name:HERTEL, REBBECCA
Entity Type:Individual
Prefix:
First Name:REBBECCA
Middle Name:
Last Name:HERTEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 PEACH ST STE 200
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16501-2134
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 PEACH ST STE 200
Practice Address - Street 2:SUITE 200
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16501-2134
Practice Address - Country:US
Practice Address - Phone:814-877-8140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS014202207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1022999190002Medicaid
PA153379Medicare PIN