Provider Demographics
NPI:1609860576
Name:FOSTERBROOK MEDICAL ASSOCIATES, PC
Entity Type:Organization
Organization Name:FOSTERBROOK MEDICAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:KIRSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-368-5402
Mailing Address - Street 1:1223 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16701-3223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1223 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-3223
Practice Address - Country:US
Practice Address - Phone:814-368-5402
Practice Address - Fax:814-368-8155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038201E207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAB40118Medicare UPIN
PA=========Medicare ID - Type Unspecified