Provider Demographics
NPI:1831169572
Name:EDGELL, PENNE
Entity type:Individual
Prefix:
First Name:PENNE
Middle Name:
Last Name:EDGELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:792 GALLITZIN RD
Mailing Address - Street 2:
Mailing Address - City:CRESSON
Mailing Address - State:PA
Mailing Address - Zip Code:16630-2213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 9TH AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-2415
Practice Address - Country:US
Practice Address - Phone:814-941-8811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD057104L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
056175OtherBILLING PROVIDER #
PA0017460580002Medicaid
PA0017460580002Medicaid
PA855597EQWMedicare PIN