Basic Information
| Provider Information | |||||||||
| NPI: | 1497967657 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICHELITCH | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 629-D LOWTHER ROAD | ||||||||
| Address2: | |||||||||
| City: | LEWISBERRY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173399527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7179325200 | ||||||||
| FaxNumber: | 7179323095 | ||||||||
| Practice Location | |||||||||
| Address1: | 629-D LOWTHER ROAD | ||||||||
| Address2: | |||||||||
| City: | LEWISBERRY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173399527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7179325200 | ||||||||
| FaxNumber: | 7179323095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 01/17/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD434244 | PA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MT184112 | PA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1022046010001 | 05 | PA | MEDICAID | 415545900 | 05 | MD | MEDICAID |