Provider Demographics
NPI:1356309223
Name:CENTRAL PENNSYLVANIA PULMONARY ASSOCIATES LLC
Entity Type:Organization
Organization Name:CENTRAL PENNSYLVANIA PULMONARY ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:717-724-2791
Mailing Address - Street 1:2250 MILLENIUM WAY
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ENOLA
Mailing Address - State:PA
Mailing Address - Zip Code:17025-1488
Mailing Address - Country:US
Mailing Address - Phone:717-724-2791
Mailing Address - Fax:717-724-2797
Practice Address - Street 1:2250 MILLENIUM WAY
Practice Address - Street 2:STE 400
Practice Address - City:ENOLA
Practice Address - State:PA
Practice Address - Zip Code:17025-1488
Practice Address - Country:US
Practice Address - Phone:717-724-2791
Practice Address - Fax:717-724-2797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2176430000OtherPERSONAL CHOICE PPO
02753200OtherCAPITAL BLUE CROSS
1547028OtherGATEWAY
PA001957188 0002Medicaid
1485178OtherHIGHMARK
7578487OtherAETNA NON HMO
3841362OtherAETNA HMO
20042172OtherAMERIHEALTH MERCY
02753200OtherCAPITAL BLUE CROSS
072274Medicare ID - Type Unspecified