Provider Demographics
NPI:1659608982
Name:FERNAN FAMILY PRACTICE
Entity Type:Organization
Organization Name:FERNAN FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEE
Authorized Official - Middle Name:M
Authorized Official - Last Name:FERNAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:814-772-0722
Mailing Address - Street 1:200 S. MILL ST.
Mailing Address - Street 2:
Mailing Address - City:RIDGWAY
Mailing Address - State:PA
Mailing Address - Zip Code:15853
Mailing Address - Country:US
Mailing Address - Phone:814-772-0722
Mailing Address - Fax:814-772-6934
Practice Address - Street 1:200 S. MILL ST.
Practice Address - Street 2:
Practice Address - City:RIDGWAY
Practice Address - State:PA
Practice Address - Zip Code:15853
Practice Address - Country:US
Practice Address - Phone:814-772-0722
Practice Address - Fax:814-772-6934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-06
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS013170207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101638607 0006Medicaid