Provider Demographics
NPI:1104827617
Name:PHELPS, WILLIAM RUDOLPH (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:RUDOLPH
Last Name:PHELPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 WALTEN POINT
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16511
Mailing Address - Country:US
Mailing Address - Phone:814-323-8630
Mailing Address - Fax:
Practice Address - Street 1:101 WALTEN POINT
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16511
Practice Address - Country:US
Practice Address - Phone:814-323-8630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD018501208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006381810010Medicaid
PA0006381810010Medicaid
PA081983E7CMedicare PIN
PA1039915OtherGATEWAY
PA3984169OtherAETNA
PA020050272OtherRR MEDICARE
PA081983OtherBLUE SHIELD
NY00764365OtherNY MEDIDAL ASSISTANCE
OH0513153OtherOH MEDICAL ASSISTANCE
PA304587OtherUPMC
C29280Medicare UPIN
PA165901OtherUNISON
WV1068882OtherW. VIRGINIA WORKERS COMP