Provider Demographics
NPI:1396715389
Name:SLATE BELT FAMILY PRACTICE PC
Entity type:Organization
Organization Name:SLATE BELT FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BROTZMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:610-863-3019
Mailing Address - Street 1:826 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WIND GAP
Mailing Address - State:PA
Mailing Address - Zip Code:18091-1628
Mailing Address - Country:US
Mailing Address - Phone:610-863-3019
Mailing Address - Fax:610-863-6732
Practice Address - Street 1:826 S BROADWAY
Practice Address - Street 2:
Practice Address - City:WIND GAP
Practice Address - State:PA
Practice Address - Zip Code:18091-1628
Practice Address - Country:US
Practice Address - Phone:610-863-3019
Practice Address - Fax:610-863-6732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-006844L207Q00000X
PAOS-007427L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA122737Medicare PIN