Provider Demographics
NPI:1609870054
Name:BRUBAKER, HERMAN WALLACE (MD)
Entity Type:Individual
Prefix:
First Name:HERMAN
Middle Name:WALLACE
Last Name:BRUBAKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:785 5TH AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-4232
Mailing Address - Country:US
Mailing Address - Phone:717-263-9555
Mailing Address - Fax:717-217-4218
Practice Address - Street 1:12 ST PAUL DR STE 101
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-1035
Practice Address - Country:US
Practice Address - Phone:717-217-6760
Practice Address - Fax:717-217-6912
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD028694E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA080086589OtherRAILROAD MEDICARE
PA4397945OtherAETNA NON-HMO
PA867633OtherMEDICARE GROUP #
PA25-1716306OtherMULTIPLAN/PHCS
PA426224OtherHEALTH AMERICA
PAP006020OtherGATEWAY
PA1806901OtherCAPITAL BLUECROSS
PA25-1716306OtherINFORMED
PA25-1716306OtherDEVON
PA25-1716306OtherSOUTH CENTRAL PREFERRED
PA000908788Medicaid
PA247728OtherMAMSI
PA122715OtherUNISON
PA666058OtherFIRST HEALTH
PAMD028694EOtherLICENSE
PA120420409OtherDEPT OF LABOR
PA25-1716306OtherINTERGROUP
PA25-1716306OtherGREATWEST
PA842753OtherAETNA HMO
PABR426736OtherHIGHMARK BLUE SHIELD
PABR426736OtherHIGHMARK BLUE SHIELD
PA25-1716306OtherSOUTH CENTRAL PREFERRED
PA00908788 0005Medicaid