Provider Demographics
NPI:1477547644
Name:PAGENKOPF, GARY LEE (DC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LEE
Last Name:PAGENKOPF
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14603 RIDGE RD
Mailing Address - Street 2:PO BOX 102
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:16443-1631
Mailing Address - Country:US
Mailing Address - Phone:814-922-3800
Mailing Address - Fax:814-922-7706
Practice Address - Street 1:14603 RIDGE RD
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:PA
Practice Address - Zip Code:16443-1631
Practice Address - Country:US
Practice Address - Phone:814-922-3800
Practice Address - Fax:814-922-7706
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC-002428-L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA6667738OtherCIGNA
PA0662096OtherAETNA
PA153721Medicaid
PA1500250Medicaid
OH232382179-00OtherOHIO WORKER'S COMPENSATIO
PA4644065OtherAETNA
PA714767OtherHIGHMARK
PA0008625260001Medicaid
OH0492293Medicaid
PA104767OtherHIGHMARK INDIVIDUAL
PA210837OtherUPMC
PA0662096OtherAETNA
T30724Medicare UPIN