Provider Demographics
NPI:1922068162
Name:LONGENBACH, ERIC WARREN (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:WARREN
Last Name:LONGENBACH
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:PO BOX 824112
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-4112
Mailing Address - Country:US
Mailing Address - Phone:215-871-6910
Mailing Address - Fax:215-871-6905
Practice Address - Street 1:217 KING ST
Practice Address - Street 2:
Practice Address - City:LAPORTE
Practice Address - State:PA
Practice Address - Zip Code:18626
Practice Address - Country:US
Practice Address - Phone:570-946-5101
Practice Address - Fax:570-946-4341
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD027396E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000945182Medicaid
PA923651OtherAETNA
PA001730OtherFIRST PRIORITY HEALTH
PAB38831OtherHEALTHAMERICA
PA177535OtherUNITEDHEALTHCARE
PA138091OtherHIGHMARK BLUE SHIELD
B38831Medicare UPIN
PA177535OtherUNITEDHEALTHCARE
PA138091Medicare PIN
PA138091OtherHIGHMARK BLUE SHIELD