Provider Demographics
NPI:1366409062
Name:DEVORE, PHILIP CHARLES (DO)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:CHARLES
Last Name:DEVORE
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 1:115 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH EAST
Mailing Address - State:PA
Mailing Address - Zip Code:16428-1330
Mailing Address - Country:US
Mailing Address - Phone:814-725-8774
Mailing Address - Fax:814-725-2391
Practice Address - Street 1:115 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH EAST
Practice Address - State:PA
Practice Address - Zip Code:16428-1330
Practice Address - Country:US
Practice Address - Phone:814-725-8774
Practice Address - Fax:814-725-2391
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABD8592594207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013007010001Medicaid
PADE1749598OtherBLUE SHIELD/KEYSTONE
PAI30539Medicare UPIN
PA1013007010001Medicaid