Provider Demographics
NPI:1336100643
Name:FREEPORT MEDICAL ASSOCIATES, INC.
Entity Type:Organization
Organization Name:FREEPORT MEDICAL ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAKDIDEJ
Authorized Official - Middle Name:
Authorized Official - Last Name:SUWAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:724-295-5202
Mailing Address - Street 1:419 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:PA
Mailing Address - Zip Code:16229-1121
Mailing Address - Country:US
Mailing Address - Phone:724-295-5202
Mailing Address - Fax:724-295-1160
Practice Address - Street 1:419 MARKET ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:PA
Practice Address - Zip Code:16229-1121
Practice Address - Country:US
Practice Address - Phone:724-295-5202
Practice Address - Fax:724-295-1160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD014710Y207R00000X, 207RI0200X
PAMD014950Y208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA732119OtherBLUE SHIELD
PA0006560450001Medicaid