Provider Demographics
NPI:1982686226
Name:CENTRAL PENN GASTROENTEROLOGY ASSOCIATES
Entity Type:Organization
Organization Name:CENTRAL PENN GASTROENTEROLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VLADIMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:PETORAK
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:570-524-2722
Mailing Address - Street 1:90 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837-9419
Mailing Address - Country:US
Mailing Address - Phone:570-524-2722
Mailing Address - Fax:570-524-0362
Practice Address - Street 1:90 MEDICAL PARK DRIVE
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837-9419
Practice Address - Country:US
Practice Address - Phone:570-524-2722
Practice Address - Fax:570-524-0362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018133010005Medicaid
PA040173Medicare ID - Type Unspecified