Provider Demographics
NPI:1689105165
Name:DR.CHARLES YEAGER LLC
Entity Type:Organization
Organization Name:DR.CHARLES YEAGER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:YEAGER
Authorized Official - Suffix:IV
Authorized Official - Credentials:DPM
Authorized Official - Phone:717-475-1455
Mailing Address - Street 1:29 CLOISTER AVE
Mailing Address - Street 2:
Mailing Address - City:EPHRATA
Mailing Address - State:PA
Mailing Address - Zip Code:17522-1701
Mailing Address - Country:US
Mailing Address - Phone:717-733-5556
Mailing Address - Fax:717-721-8139
Practice Address - Street 1:1 MASONIC DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:PA
Practice Address - Zip Code:17022-2199
Practice Address - Country:US
Practice Address - Phone:717-367-1121
Practice Address - Fax:717-361-4525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002211L332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000587897Medicaid
PAT29716Medicare UPIN