Provider Demographics
NPI:1689640823
Name:GEORGETSON, MICHAEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:GEORGETSON
Suffix:
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 1:1 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 1:1 GUTHRIE SQ
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-1625
Practice Address - Country:US
Practice Address - Phone:570-888-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174652-1207RG0100X
PAMD036907E207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC8362OtherRR MEDICARE GROUP
NYP00379066OtherRR MEDICARE PIN
PAGU039897OtherMEDICARE GROUP
PA100014270OtherRR MEDICARE PIN
PA0010736000002Medicaid
PACC9269OtherRR MEDICARE GROUP
PACC9269OtherRR MEDICARE GROUP
NYP00379066OtherRR MEDICARE PIN
PAGU039897OtherMEDICARE GROUP