Provider Demographics
NPI:1487627857
Name:QUEEN STREET FAMILY PRACTICE PC
Entity Type:Organization
Organization Name:QUEEN STREET FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:HIGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:717-741-3888
Mailing Address - Street 1:2471 S QUEEN ST
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-4947
Mailing Address - Country:US
Mailing Address - Phone:717-741-3888
Mailing Address - Fax:717-741-3709
Practice Address - Street 1:2471 S QUEEN ST
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-4947
Practice Address - Country:US
Practice Address - Phone:717-741-3888
Practice Address - Fax:717-741-3709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA02739200OtherCAPITOL BLUE CROSS
PAL0472628OtherPA BLUE SHIELD
PA0010615660001Medicaid
PA4I4T2629OtherPA BLUE SHIELD
PA0010615750001Medicaid
B42141Medicare UPIN
PAL0472628OtherPA BLUE SHIELD
D98800Medicare UPIN
472628JK2Medicare ID - Type Unspecified