Provider Demographics
NPI:1174553408
Name:FOGG, ANNA (MSPT)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:FOGG
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 FISHER RUN RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-7435
Mailing Address - Country:US
Mailing Address - Phone:570-332-5280
Mailing Address - Fax:
Practice Address - Street 1:303 FISHER RUN RD
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-7435
Practice Address - Country:US
Practice Address - Phone:570-332-5280
Practice Address - Fax:570-332-5280
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2021-03-25
Deactivation Date:2016-10-11
Deactivation Code:
Reactivation Date:2021-03-25
Provider Licenses
StateLicense IDTaxonomies
PAPT016699L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3689029OtherAETNA HMO PROVIDER #
PA50038611OtherCAPITAL BLUE CROSS #
PA372926OtherHIGHMARK BS GROUP NO.
PA394508Medicare ID - Type UnspecifiedGROUP PROVIDER NO