Basic Information
Provider Information
NPI: 1003803099
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: EVANS
FirstName: RICHARD
MiddleName: G
NamePrefix:  
NameSuffix:  
Credential: D.O.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 50 N 12TH ST
Address2:  
City: LEMOYNE
State: PA
PostalCode: 170431440
CountryCode: US
TelephoneNumber: (717) 234-2561
FaxNumber: 7172361121
Practice Location
Address1: 50 N 12TH ST
Address2:  
City: LEMOYNE
State: PA
PostalCode: 170431440
CountryCode: US
TelephoneNumber: 7172342561
FaxNumber: 7172361121
Other Information
ProviderEnumerationDate: 10/04/2005
LastUpdateDate: 03/17/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207RP1001XOS006561LPAY Allopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease

ID Information
IDTypeStateIssuerDescription
001189437000205PA MEDICAID


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