Provider Demographics
NPI:1487631214
Name:FATH, MICHAEL E (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:E
Last Name:FATH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:575 PIERCE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-5700
Mailing Address - Country:US
Mailing Address - Phone:570-718-8676
Mailing Address - Fax:570-338-2345
Practice Address - Street 1:575 PIERCE ST STE 101
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5700
Practice Address - Country:US
Practice Address - Phone:570-718-8676
Practice Address - Fax:570-338-2345
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012073207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001458607OtherBLUE CROSS BLUE SHIELD
PA001947548Medicaid
PA002993OtherFIRST PRIORITY
PA002993OtherFIRST PRIORITY
PA068053XZBMedicare PIN
PA001947548Medicaid