Provider Demographics
NPI:1780644757
Name:FARIES, GEORGE BONNELL JR (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:BONNELL
Last Name:FARIES
Suffix:JR
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 1:3 WALNUT ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:LEMOYNE
Mailing Address - State:PA
Mailing Address - Zip Code:17043-1168
Mailing Address - Country:US
Mailing Address - Phone:717-761-0208
Mailing Address - Fax:717-761-2023
Practice Address - Street 1:532 N FRONT ST
Practice Address - Street 2:
Practice Address - City:WORMLEYSBURG
Practice Address - State:PA
Practice Address - Zip Code:17043-1016
Practice Address - Country:US
Practice Address - Phone:717-761-4141
Practice Address - Fax:717-761-1456
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD010337E208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
C27614Medicare UPIN
PA019258Medicare ID - Type Unspecified