Provider Demographics
NPI:1336416940
Name:HARTZELL RUPP OPHTHALMOLOGY P.C.
Entity Type:Organization
Organization Name:HARTZELL RUPP OPHTHALMOLOGY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:RUPP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:717-766-1566
Mailing Address - Street 1:3 BADEN POWELL LN
Mailing Address - Street 2:SUITE 4
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17050-5270
Mailing Address - Country:US
Mailing Address - Phone:717-766-1566
Mailing Address - Fax:717-766-2604
Practice Address - Street 1:3 BADEN POWELL LN
Practice Address - Street 2:SUITE 4
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17050-5270
Practice Address - Country:US
Practice Address - Phone:717-766-1566
Practice Address - Fax:717-766-2604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-27
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD417246207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
055419MZVOtherPTAN
PA1008425800001Medicaid
PA1008425800001Medicaid