Provider Demographics
NPI:1356927818
Name:EBERSOLE, BRYCE
Entity type:Individual
Prefix:
First Name:BRYCE
Middle Name:
Last Name:EBERSOLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3369 ROUTE 100
Mailing Address - Street 2:
Mailing Address - City:MACUNGIE
Mailing Address - State:PA
Mailing Address - Zip Code:18062-9613
Mailing Address - Country:US
Mailing Address - Phone:835-215-5500
Mailing Address - Fax:
Practice Address - Street 1:3369 ROUTE 100
Practice Address - Street 2:
Practice Address - City:MACUNGIE
Practice Address - State:PA
Practice Address - Zip Code:18062-9613
Practice Address - Country:US
Practice Address - Phone:835-215-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-23
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAOS023637207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program