Provider Demographics
NPI:1942325592
Name:THOMAS R. ELLENBERGER, JR MD PC
Entity Type:Organization
Organization Name:THOMAS R. ELLENBERGER, JR MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:ELLENBERGER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:814-535-7885
Mailing Address - Street 1:321 MAIN ST STE 5D
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15901-1632
Mailing Address - Country:US
Mailing Address - Phone:814-535-7885
Mailing Address - Fax:814-535-7079
Practice Address - Street 1:321 MAIN ST STE 5D
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15901-1632
Practice Address - Country:US
Practice Address - Phone:814-535-7885
Practice Address - Fax:814-535-7079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD018414E261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA027796OtherHIGHMARK
PA0006378450001Medicaid
PA11978OtherUPMC HEALTH PLAN
0743755OtherUMWA
PA027796OtherHIGHMARK
EL27796Medicare ID - Type Unspecified