Provider Demographics
NPI:1285620641
Name:PROVOST, GEORGE L (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:L
Last Name:PROVOST
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 1:421 W CHEW ST
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18102-3406
Mailing Address - Country:US
Mailing Address - Phone:610-776-5100
Mailing Address - Fax:610-663-3113
Practice Address - Street 1:1210 HANOVER AVE
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18109-2017
Practice Address - Country:US
Practice Address - Phone:610-437-6490
Practice Address - Fax:610-437-4151
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD020842E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017584420001Medicaid
014563OtherHIGHMARK
P002518OtherGATEWAY
0040759000OtherIBC
20011415OtherAMERIHEALTH MERCY HEALTH
01371901OtherCBC
01371901OtherCBC
PA014563JKKMedicare PIN
PA010057335Medicare PIN