Provider Demographics
NPI:1245291848
Name:GEORGE E. FAVA MD PC
Entity type:Organization
Organization Name:GEORGE E. FAVA MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:C
Authorized Official - Last Name:MARIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:717-821-1481
Mailing Address - Street 1:875 NORMAN DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-7454
Mailing Address - Country:US
Mailing Address - Phone:717-272-2010
Mailing Address - Fax:717-272-2937
Practice Address - Street 1:875 NORMAN DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7454
Practice Address - Country:US
Practice Address - Phone:717-272-2010
Practice Address - Fax:717-272-2937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0721850001Medicare NSC
538719Medicare ID - Type Unspecified