Provider Demographics
NPI:1376685164
Name:YEAGER, HENRY C III (MD)
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:C
Last Name:YEAGER
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:PA
Mailing Address - Zip Code:18471-0407
Mailing Address - Country:US
Mailing Address - Phone:570-563-1012
Mailing Address - Fax:570-563-2993
Practice Address - Street 1:746 JEFFERSON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-1624
Practice Address - Country:US
Practice Address - Phone:570-347-8391
Practice Address - Fax:570-347-8396
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD016373E171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0001188663002Medicaid
PA0001188663002Medicaid
PA123134Medicare ID - Type UnspecifiedPROVIDER NUMBER