Provider Demographics
NPI:1720118268
Name:BRACKBILL, ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:
Last Name:BRACKBILL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 WYOMISSING BLVD
Mailing Address - Street 2:
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-2268
Mailing Address - Country:US
Mailing Address - Phone:610-378-9449
Mailing Address - Fax:
Practice Address - Street 1:1011 BERK RD
Practice Address - Street 2:
Practice Address - City:LEESPORT
Practice Address - State:PA
Practice Address - Zip Code:19533-8705
Practice Address - Country:US
Practice Address - Phone:610-376-4841
Practice Address - Fax:610-372-6642
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD024684E208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMD024684EOtherLICENSE NUMBER
PA0992727Medicaid
PAB36196Medicare UPIN