Basic Information
| Provider Information | |||||||||
| NPI: | 1033322466 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY PRACTICE CENTER, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 DOCK HILL RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178428910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708372123 | ||||||||
| FaxNumber: | 5708372185 | ||||||||
| Practice Location | |||||||||
| Address1: | 270 SUSQUEHANNA VALLEY MALL DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | SELINSGROVE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178709115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708847920 | ||||||||
| FaxNumber: | 5708847928 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2007 | ||||||||
| LastUpdateDate: | 05/13/2020 | ||||||||
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| AuthorizedOfficialLastName: | DARRUP | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | LABORATORY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5708375889 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 05/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 020650 | PA | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 39D0657424 | 01 | PA | CLIA | OTHER | 690004734 | 01 | GA | MCRR PIN | OTHER |