Basic Information
| Provider Information | |||||||||
| NPI: | 1164460135 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAIRWAY MEDICAL ASSOCIATES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 144 S 8TH ST | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | CHAMBERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172012755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172646511 | ||||||||
| FaxNumber: | 7172641081 | ||||||||
| Practice Location | |||||||||
| Address1: | 144 S 8TH ST | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | CHAMBERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172012767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172646511 | ||||||||
| FaxNumber: | 7172641081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 10/30/2014 | ||||||||
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| AuthorizedOfficialLastName: | BRICKER | ||||||||
| AuthorizedOfficialFirstName: | SAMUEL | ||||||||
| AuthorizedOfficialMiddleName: | Q | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 7172646511 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0009928520001 | 05 | PA | MEDICAID |