Provider Demographics
NPI:1174582266
Name:HALCOVAGE, JOHN SAMUEL (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:SAMUEL
Last Name:HALCOVAGE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4240 ACADEMY DRIVE
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17112-1091
Mailing Address - Country:US
Mailing Address - Phone:717-652-1139
Mailing Address - Fax:
Practice Address - Street 1:1700 SOUTH LINCOLN AVENUE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042
Practice Address - Country:US
Practice Address - Phone:717-272-6621
Practice Address - Fax:717-228-6045
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-008090-L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01529584Medicaid
PA01529584Medicaid
PA472917Medicare ID - Type Unspecified