DR. WYNNE ANN HOFFACKER M.D.
Complete NPI Record 1528090321
Family Medicine in East Berlin, PA

Active since July 06, 2006PECOS Enrolled

105 4TH ST, EAST BERLIN, PA 17316(717) 846-4644(717) 259-7262 Get Directions

NPPES record last updated: March 13, 2024. Verified against the NPPES registry weekly; last sync: August 02, 2026.

Record update history: Jul 15, 2021, Jul 15, 2016 (2 updates tracked since 2016).

Complete NPI Dataset

This page contains the complete raw NPPES record for Dr. Wynne Ann Hoffacker, M.D. (NPI 1528090321), an individual family medicine provider in East Berlin, PA. All 87 fields on file are listed with their current values and official NPPES definitions, exactly as recorded in the National Plan and Provider Enumeration System. Only fields that contain data are included, so the number of fields shown varies from one NPI record to another.

Use the tools below to filter fields by category, search within the record, or jump straight to a specific field. You can download the full record as a CSV, JSON, Markdown or text file, or filter first and export only the fields you need. The Print Clean Summary button produces a printer-friendly copy of the record.

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NPI: 1528090321: The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
Entity Type Code: 1: Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
Provider Last Name Legal Name: HOFFACKER: The last name of the provider. If the provider is an individual, this is the legal name.
Provider First Name: WYNNE: The first name of the provider, if the provider is an individual.
Provider Middle Name: ANN: The middle name of the provider, if the provider is an individual.
Provider Name Prefix Text: DR.: The name prefix or salutation of the provider if the provider is an individual; for example, Mr., Mrs., or Corporal.
Provider Credential Text: M.D.: The abbreviations for professional degrees or credentials used or held by the provider, if the provider is an individual. Examples are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations will not be verified by NPS.
Provider Other Last Name: BRINKS: Other last name by which the provider being identified is or has been known.
Provider Other First Name: WYNNE: Other first name by which the provider being identified is or has been known (if an individual). This may be the same as the "Provider first name" if the provider is or has been known by a different last name only.
Provider Other Middle Name: ANN: Other middle name by which the provider being identified is or has been known (if an individual). This may be the same as the "Provider middle name" if the provider is or has been known by a different last name only.
Provider Other Name Prefix Text: DR.: The other name prefix or salutation of the provider if the provider is an individual; for example, Mr., Mrs., or Corporal.
Provider Other Credential Text: M.D.: The other abbreviations for professional degrees or credentials used or held by the provider, if the provider is an individual. Examples are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations will not be verified by NPS.
Provider Other Last Name Type Code: 5: Code identifying the type of other name. Codes are: 1 = former name; 2 = professional name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other.
Provider First Line Business Mailing Address: 601 MEMORY LN: The first line mailing address of the provider being identified. This data element may contain the same information as "Provider first line location address".
Provider Business Mailing Address City Name: YORK: The city name in the mailing address of the provider being identified.
Provider Business Mailing Address State Name: PA: The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address State name".
Provider Business Mailing Address Postal Code: 174022231: The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as "Provider location address postal code".
Provider Business Mailing Address Country Code If outside U S : US: The country code in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address country code".
Provider Business Mailing Address Telephone Number: 7178124900: The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as "Provider location address telephone number".
Provider Business Mailing Address Fax Number: 7172550951: The fax number associated with the mailing address of the provider being identified. This data element may contain the same information as "Provider location address fax number".
Provider First Line Business Practice Location Address: 105 4TH ST: The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Business Practice Location Address City Name: EAST BERLIN: The city name in the location address of the provider being identified.
Provider Business Practice Location Address State Name: PA: The State code in the location of the provider being identified.
Provider Business Practice Location Address Postal Code: 173169638: The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
Provider Business Practice Location Address Country Code If outside U S : US: The country code in the location address of the provider being identified.
Provider Business Practice Location Address Telephone Number: 7178464644: The telephone number associated with the location address of the provider being identified.
Provider Business Practice Location Address Fax Number: 7172597262: The fax number associated with the location address of the provider being identified.
Provider Enumeration Date: 7/6/2006: The date the provider was assigned a unique identifier (assigned an NPI).
Last Update Date: 3/13/2024: The date that a record was last updated or changed.
Provider Gender Code: F: The code designating the provider's gender if the provider is a person.
Healthcare Provider Taxonomy Code 1: 207Q00000X: This field represents the provider's taxonomy code, which classifies their type, classification, and area of specialization. This code comes from the Healthcare Provider Taxonomy Code Set maintained by the National Uniform Claim Committee (NUCC). The NPS will associate these data with the license data for providers with Entity type code = 1.
Provider License Number 1: MD057567L: The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with "provider taxonomy code".
Provider License Number State Code 1: PA: The two-letter state code representing the U.S. state or territory that issued the provider's license. This field is linked to the Provider License Number field and identifies the jurisdiction where that license is valid. A provider may have multiple state codes if they hold licenses in more than one state.
Healthcare Provider Primary Taxonomy Switch 1: Y: This field shows whether the related taxonomy code is the provider's primary specialty. It is a single-character value: "Y" indicates the taxonomy is the primary one, while "N" indicates it is not. Each provider record can have only one taxonomy code marked as primary.
Other Provider Identifier 1: 30123009 - CAREEXP.: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 1: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 1: PA: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier Issuer 1: AMERIHEALTH MERCY - WMG: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 2: 30123010 - RDYCARE: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 2: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 2: PA: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier Issuer 2: AMERIHEALTH MERCY - WMG: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 3: 80909: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 3: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 3: PA: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier Issuer 3: UNISON-WMG: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 4: 95759: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 4: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 4: PA: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier Issuer 4: GEISINGER: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 5: 30033: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 5: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 5: PA: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier Issuer 5: JOHNS HOPKINS: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 6: P002801: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 6: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 6: PA: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier Issuer 6: GATEWAY-WMG: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 7: 001563960: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 7: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 7: PA: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 8: 238929: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 8: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 8: PA: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier Issuer 8: MAMSI-WMG: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 9: 842830: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 9: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 9: PA: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier Issuer 9: HIGHMARK BLUE SHIELD: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 10: 542991: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 10: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 10: MD: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier Issuer 10: CAREFIRST MD BCBS: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 11: 01059102: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 11: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 11: PA: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier Issuer 11: CAPITAL BLUE CROSS-WMG: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 12: 1142351: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 12: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 12: PA: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier Issuer 12: AMERIHEALTH MERCY-WMG: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 13: 4516556: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 13: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 13: PA: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier Issuer 13: AETNA: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Is Sole Proprietor: N: Indicates whether the provider is registered as a sole proprietor. This is a single-character code: "Y" means the provider operates as a sole proprietor, and "N" means they do not.
NPI Certification Date: 3/12/2024: The date on which the National Provider Identifier (NPI) was officially assigned and certified to the provider. This reflects when the provider's NPI record first became active in the NPPES system.

Secondary Practice Locations 43

The first line of the secondary practice location address of the provider being identified. For providers with more than one physical location, this is a secondary practice location address. This address cannot include a Post Office box.

1227 Baltimore St

1/43

Hanover, PA 17331-4406 · Phone (717) 812-5190

2149 S Queen St

2/43

York, PA 17403-4845 · Phone (717) 356-4460

100 Eisenhower Dr

3/43

Hanover, PA 17331-5241 · Phone (717) 646-4201

101 W Airport Rd

4/43

Lititz, PA 17543-9274 · Phone (717) 466-2445

2250 E Market St

5/43

York, PA 17402-2857 · Phone (717) 851-1566

9 Nathan Ln

6/43

Annville, PA 17003-6500 · Phone (717) 639-3350

96 Sofia Dr Ste 208

7/43

Shrewsbury, PA 17361-5201 · Phone (717) 812-2400

4050 N George Street Ext

8/43

Manchester, PA 17345-9347 · Phone (717) 356-4370

446 N Reading Rd

9/43

Ephrata, PA 17522-9802 · Phone (717) 738-5275

455 S Washington St Ste 12

10/43

Gettysburg, PA 17325-2516 · Phone (717) 339-2875

717 Town Center Dr

11/43

York, PA 17408-4824 · Phone (717) 356-4240

52 Water St

12/43

Thurmont, MD 21788-1912 · Phone (717) 356-5198

2900 Carlisle Pike

13/43

New Oxford, PA 17350-8426 · Phone (717) 812-2554

10 Muddy Creek Forks Rd Ste 3

14/43

Brogue, PA 17309-9497 · Phone (717) 812-5020

755 S Pleasant Ave

15/43

Dallastown, PA 17313-9252 · Phone (717) 851-1300

430 N Main St

16/43

Spring Grove, PA 17362-1123 · Phone (717) 851-6500

100 Frederick St Ste 101

17/43

Hanover, PA 17331-3518 · Phone (717) 851-7050

2775 N George St

18/43

York, PA 17406-3020 · Phone (717) 812-7300

2350 Freedom Way Ste 150

19/43

York, PA 17402-8200 · Phone (717) 851-7315

1401 Roosevelt Ave

20/43

York, PA 17404-2244 · Phone (717) 356-6250

55 N Main St

21/43

Jacobus, PA 17407-1248 · Phone (717) 428-1911

1575 Bannister St Ste 1

22/43

York, PA 17404-4946 · Phone (717) 812-2000

4910 Fairfield Rd Ste A

23/43

Fairfield, PA 17320-9510 · Phone (717) 339-3175

2060 Carlisle Rd

24/43

Aspers, PA 17304-9707 · Phone (717) 339-2585

3065 Windsor Rd

25/43

Red Lion, PA 17356-8533 · Phone (717) 812-3040

2675 Joppa Rd

26/43

York, PA 17403-5160 · Phone (717) 741-9063

2339 S George St

27/43

York, PA 17403-5009 · Phone (717) 812-3040

2050 S Queen St Ste 100

28/43

York, PA 17403-4829 · Phone (717) 812-4240

820 Chambersburg Rd

29/43

Gettysburg, PA 17325-3310 · Phone (717) 337-4410

300 W King St Ste C

30/43

Littlestown, PA 17340-1446 · Phone (717) 339-2390

40 V Twin Dr Ste 204

31/43

Gettysburg, PA 17325-7878 · Phone (717) 339-2424

423 S Washington St

32/43

Gettysburg, PA 17325-2526 · Phone (717) 339-3165

1010 Plymouth Rd

33/43

York, PA 17402-3864 · Phone (717) 851-1800

13515 Wolfe Rd Ste C

34/43

New Freedom, PA 17349-9346 · Phone (717) 812-2501

235 Rosedale Dr

35/43

Manchester, PA 17345-1022 · Phone (717) 812-5229

605 S George St Ste 200

36/43

York, PA 17401-3161 · Phone (717) 851-2334

25 Monument Rd Ste 140

37/43

York, PA 17403-5057 · Phone (717) 741-8003

370 Saint Charles Way

38/43

York, PA 17402-4647 · Phone (717) 741-8003

4222 Lincoln Hwy

39/43

York, PA 17406-8083 · Phone (717) 812-2050

1790 Old Trail Rd

40/43

Etters, PA 17319-9652 · Phone (717) 938-6588

4020 Carlisle Rd

41/43

Dover, PA 17315-3508 · Phone (717) 851-6400

15 Constitution Ave

42/43

Shrewsbury, PA 17361-1709 · Phone (717) 235-6848

2003 E Market St

43/43

York, PA 17402-2841 · Phone (717) 812-4242

Other Provider Identifiers 13

Legacy and payer-issued identifiers reported to the NPPES registry for this provider.

30123009 - CAREEXP. Other

1/13

State: PA · Issuer: Amerihealth Mercy - Wmg
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

30123010 - RDYCARE Other

2/13

State: PA · Issuer: Amerihealth Mercy - Wmg
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

80909 Other

3/13

State: PA · Issuer: Unison-wmg
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

95759 Other

4/13

State: PA · Issuer: Geisinger
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

30033 Other

5/13

State: PA · Issuer: Johns Hopkins
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

P002801 Other

6/13

State: PA · Issuer: Gateway-wmg
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

001563960 Medicaid

7/13

State: PA
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

238929 Other

8/13

State: PA · Issuer: Mamsi-wmg
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

842830 Other

9/13

State: PA · Issuer: Highmark Blue Shield
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

542991 Other

10/13

State: MD · Issuer: Carefirst Md Bcbs
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

01059102 Other

11/13

State: PA · Issuer: Capital Blue Cross-wmg
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

1142351 Other

12/13

State: PA · Issuer: Amerihealth Mercy-wmg
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

4516556 Other

13/13

State: PA · Issuer: Aetna
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

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