Provider Demographics
NPI:1932172335
Name:PROTENIC, GEORGE M
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:M
Last Name:PROTENIC
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 1:207 N BROAD ST FL 3
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-1500
Mailing Address - Country:US
Mailing Address - Phone:267-479-4142
Mailing Address - Fax:
Practice Address - Street 1:826 MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIXVILLE
Practice Address - State:PA
Practice Address - Zip Code:19460-4459
Practice Address - Country:US
Practice Address - Phone:484-928-6780
Practice Address - Fax:267-741-0003
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA000658L363A00000X
PAMA0006581363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1031466560003Medicaid
PAQ03644Medicare UPIN