Provider Demographics
NPI:1881646859
Name:PROGRESSIVE PHYSICIAN ASSOC INC
Entity Type:Organization
Organization Name:PROGRESSIVE PHYSICIAN ASSOC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE CREDENTIALING COORDI
Authorized Official - Prefix:
Authorized Official - First Name:SUSANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEANGELO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-868-1100
Mailing Address - Street 1:95 HIGHLAND AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18017-9424
Mailing Address - Country:US
Mailing Address - Phone:610-868-1100
Mailing Address - Fax:610-868-1111
Practice Address - Street 1:95 HIGHLAND AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18017-9424
Practice Address - Country:US
Practice Address - Phone:610-868-1100
Practice Address - Fax:610-868-1111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2085R0202X, 2085R0204X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1303700Medicaid
PA1303700Medicaid