Provider Demographics
NPI:1639145956
Name:BATES, OLLICE JR (MD)
Entity Type:Individual
Prefix:
First Name:OLLICE
Middle Name:
Last Name:BATES
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 1:309 JADE AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17821-8537
Mailing Address - Country:US
Mailing Address - Phone:570-275-7698
Mailing Address - Fax:
Practice Address - Street 1:11 9TH ST
Practice Address - Street 2:
Practice Address - City:SELINSGROVE
Practice Address - State:PA
Practice Address - Zip Code:17870-8409
Practice Address - Country:US
Practice Address - Phone:570-374-7799
Practice Address - Fax:570-374-3469
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD013557E207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0689716Medicaid
BA123584Medicare ID - Type Unspecified
PA0689716Medicaid