Basic Information
| Provider Information | |||||||||
| NPI: | 1003866039 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIRDHARRY | ||||||||
| FirstName: | TYRONE | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 409 S 2ND ST STE 2F | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171041612 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 HIGHLANDS DR | ||||||||
| Address2: | |||||||||
| City: | LITITZ | ||||||||
| State: | PA | ||||||||
| PostalCode: | 175437694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177823282 | ||||||||
| FaxNumber: | 7172318964 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 01/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD420762 | PA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 0019339900001 | 05 | PA | MEDICAID |