Provider Demographics
NPI:1669440707
Name:INGERICK, BRENT S (DO)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:S
Last Name:INGERICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:1336 CEDAR ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14904-2951
Practice Address - Country:US
Practice Address - Phone:607-734-3929
Practice Address - Fax:607-734-0781
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012494207Q00000X
NY232476-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1012062540001Medicaid
NY02581455Medicaid
PAGU039851OtherMEDICARE GROUP
PAP00337166OtherRR MEDICARE PIN
NYCC8362OtherRR MEDICARE GROUP
NYP00173974OtherRR MEDICARE PIN
PACC9269OtherRR MEDICARE GROUP
PACC9269OtherRR MEDICARE GROUP
PAGU039851OtherMEDICARE GROUP
PAP00337166OtherRR MEDICARE PIN