Provider Demographics
NPI:1639118797
Name:ERDMAN, KENNETH LEE JR (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:LEE
Last Name:ERDMAN
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7 DOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:570-837-2185
Practice Address - Street 1:2813 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:MIFFLINTOWN
Practice Address - State:PA
Practice Address - Zip Code:17059-9078
Practice Address - Country:US
Practice Address - Phone:717-436-8283
Practice Address - Fax:717-436-5594
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS010955L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018482810003Medicaid
PA052133F6KMedicare PIN
PA052133F6KMedicare PIN