Provider Demographics
NPI:1619904497
Name:HETRICK, THEODORE L JR (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:L
Last Name:HETRICK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17044-1167
Mailing Address - Country:US
Mailing Address - Phone:717-242-7180
Mailing Address - Fax:717-242-7299
Practice Address - Street 1:400 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:PA
Practice Address - Zip Code:17044-1167
Practice Address - Country:US
Practice Address - Phone:717-242-7180
Practice Address - Fax:717-242-7299
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD018356E207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
058797Medicare ID - Type Unspecified
C28575Medicare UPIN