Provider Demographics
NPI:1477669901
Name:CLEARBROOK FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:CLEARBROOK FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:E
Authorized Official - Last Name:HENNINGER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:814-684-1245
Mailing Address - Street 1:863 S LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:PA
Mailing Address - Zip Code:16686-1349
Mailing Address - Country:US
Mailing Address - Phone:814-684-1245
Mailing Address - Fax:814-684-1246
Practice Address - Street 1:863 S LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:PA
Practice Address - Zip Code:16686-1349
Practice Address - Country:US
Practice Address - Phone:814-684-1245
Practice Address - Fax:814-684-1246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS009583L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADB3021OtherRAILROAD MEDICARE
PA1496395OtherHIGHMARK BLUE CROSS
PA42600OtherGEISINGER
PA265732OtherHEALTH AMERICA
PA204685OtherUPMC
PAG86767Medicare UPIN
PA1496395OtherHIGHMARK BLUE CROSS