Provider Demographics
NPI:1629064530
Name:LABOSH, TIMOTHY J (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:LABOSH
Suffix:
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 1:5665 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAST PETERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17520-1513
Mailing Address - Country:US
Mailing Address - Phone:717-569-7011
Mailing Address - Fax:717-569-8694
Practice Address - Street 1:5665 MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST PETERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17520-1513
Practice Address - Country:US
Practice Address - Phone:717-569-7011
Practice Address - Fax:717-569-8694
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042074E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA40026 S1QCOtherGEISINGER HEALTH PLAN
PA604065OtherHIGHMARK BLUE SHIELD
PA0015297170003Medicaid
PA01957301OtherCAPITAL BLUE CROSS
PA515152OtherAETNA HMO
PA5818042OtherAETNA NON-HMO
PAP002630OtherGATEWAY HEALTH PLAN
PAE53671OtherHEALTH ASSURANCE
PA604065OtherHIGHMARK BLUE SHIELD
PA40026 S1QCOtherGEISINGER HEALTH PLAN