Provider Demographics
NPI:1508818410
Name:ELLENBERGER, THOMAS RICHARD JR (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:RICHARD
Last Name:ELLENBERGER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:130 ROLLING HILLS RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-5224
Mailing Address - Country:US
Mailing Address - Phone:814-535-7885
Mailing Address - Fax:814-535-7079
Practice Address - Street 1:321 MAIN ST
Practice Address - Street 2:SUITE 5D
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15901-1632
Practice Address - Country:US
Practice Address - Phone:814-535-7885
Practice Address - Fax:814-535-7079
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD018414E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006378450001Medicaid
PA027796OtherHIGHMARK
0743755OtherUMWA
PA11978OtherUPMC HEALTH PLAN
PA11978OtherUPMC HEALTH PLAN
PA027796OtherHIGHMARK