Individual
GEORGE L PROVOST
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1210 HANOVER AVE, ALLENTOWN, PA 18109-2017
(610) 437-6490
(610) 437-4151
Mailing address
421 W CHEW ST, ALLENTOWN, PA 18102-3406
(610) 776-5100
(610) 663-3113
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
MD020842E
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0017584420001
—
PA
01
—
0040759000
IBC
—
01
—
01371901
CBC
—
01
—
014563
HIGHMARK
—
01
—
20011415
AMERIHEALTH MERCY HEALTH
—
01
—
P002518
GATEWAY
—
Enumeration date
09/21/2005
Last updated
09/10/2010
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