Provider Demographics
NPI:1710958475
Name:MORGANTOWN FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:MORGANTOWN FAMILY PRACTICE LLC
Other - Org Name:GORDON R DONALDSON
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:R
Authorized Official - Last Name:DONALDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:610-286-9064
Mailing Address - Street 1:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19543-0488
Mailing Address - Country:US
Mailing Address - Phone:610-286-9064
Mailing Address - Fax:610-286-7832
Practice Address - Street 1:4103 MAIN ST
Practice Address - Street 2:
Practice Address - City:ELVERSON
Practice Address - State:PA
Practice Address - Zip Code:19520-9378
Practice Address - Country:US
Practice Address - Phone:610-286-9064
Practice Address - Fax:610-286-7832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-31
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1310236OtherPA BLUE SHIELD
DG2978OtherRAILROAD MEDICARE
PA1310236OtherPA BLUE SHIELD