Provider Demographics
NPI:1346217668
Name:EVERETT, EDWARD A JR (DO)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:A
Last Name:EVERETT
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:CREDENTIALS DEPT
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-2710
Practice Address - Country:US
Practice Address - Phone:570-271-8091
Practice Address - Fax:570-271-5879
Is Sole Proprietor?:No
Enumeration Date:2006-03-06
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012189208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019295770001Medicaid
H75232Medicare UPIN
PAEV064906Medicare PIN