Provider Demographics
NPI:1497732572
Name:KENHORST FAMILY MEDICAL CENTER
Entity Type:Organization
Organization Name:KENHORST FAMILY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EZZAT
Authorized Official - Middle Name:A
Authorized Official - Last Name:HANNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-775-2799
Mailing Address - Street 1:600 HIGH BLVD
Mailing Address - Street 2:PO BOX 347
Mailing Address - City:KENHORST
Mailing Address - State:PA
Mailing Address - Zip Code:19607-0347
Mailing Address - Country:US
Mailing Address - Phone:610-775-2799
Mailing Address - Fax:610-775-3284
Practice Address - Street 1:600 HIGH BLVD
Practice Address - Street 2:
Practice Address - City:KENHORST
Practice Address - State:PA
Practice Address - Zip Code:19607-0347
Practice Address - Country:US
Practice Address - Phone:610-775-2799
Practice Address - Fax:610-775-3284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
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
PA02420100OtherCAPITAL BLUE CROSS
PA503515OtherHIGHMARK BLUE SHIELD
PA503515Medicare ID - Type Unspecified