Basic Information
| Provider Information | |||||||||
| NPI: | 1649376104 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENTRUP | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 N ACADEMY AVE | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178222025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702716975 | ||||||||
| FaxNumber: | 5702716762 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 N ACADEMY AVE | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178222025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702716975 | ||||||||
| FaxNumber: | 5702716762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 08/24/2011 | ||||||||
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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 | 207L00000X | 59948 | MA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | MD441677 | PA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | MD13053 | RI | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 3039854 | 05 | MA | MEDICAID | 1025459600001 | 05 | PA | MEDICAID |