Basic Information
| Provider Information | |||||||||
| NPI: | 1639118797 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ERDMAN | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DO | ||||||||
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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: | 2813 INDUSTRIAL PARK RD | ||||||||
| Address2: | |||||||||
| City: | MIFFLINTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170599078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7174368283 | ||||||||
| FaxNumber: | 7174365594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 04/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS010955L | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0018482810003 | 05 | PA | MEDICAID |