Provider Demographics
NPI:1710389994
Name:FAYETTE PHYSICIAN NETWORK INC
Entity Type:Organization
Organization Name:FAYETTE PHYSICIAN NETWORK INC
Other - Org Name:FPN-BROWNSVILLE
Other - Org Type:Other Name
Authorized Official - Title/Position:SR.DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:EHALT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-647-0943
Mailing Address - Street 1:111B ROBERTS RD
Mailing Address - Street 2:
Mailing Address - City:GRINDSTONE
Mailing Address - State:PA
Mailing Address - Zip Code:15442-1105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111B ROBERTS RD
Practice Address - Street 2:
Practice Address - City:GRINDSTONE
Practice Address - State:PA
Practice Address - Zip Code:15442-1105
Practice Address - Country:US
Practice Address - Phone:724-785-2286
Practice Address - Fax:724-785-3187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty