1063607893 NPI number — LACKAWANNA MOBILE X-RAY, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063607893 NPI number — LACKAWANNA MOBILE X-RAY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LACKAWANNA MOBILE X-RAY, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063607893
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1229 MONROE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUNMORE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18509-2807
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-789-7082
Provider Business Mailing Address Fax Number:
800-801-7684

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1229 MONROE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUNMORE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18509-2807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-789-7082
Provider Business Practice Location Address Fax Number:
800-801-7684
Provider Enumeration Date:
09/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WOELKERS
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
570-346-5115

Provider Taxonomy Codes

  • Taxonomy code: 335V00000X , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0526476 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2771012000 . This is a "AMERIHEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 300004695 . This is a "PALMETTO MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2771012000 . This is a "BLUE CHOICE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0010364100002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2771012000 . This is a "KEYSTONE 65" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2771012000 . This is a "PERSONAL CHOICE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50002829 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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