1124222971 NPI number — POCONO CENTER FOR ORAL, FACIAL & IMPLANT SURGERY

Table of content: (NPI 1124222971)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124222971 NPI number — POCONO CENTER FOR ORAL, FACIAL & IMPLANT SURGERY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POCONO CENTER FOR ORAL, FACIAL & IMPLANT SURGERY
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:
POCONO ORAL MAXILLOFACIAL SURGERY CENTER
Provider Other Organization Name Type Code:
4
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:
1124222971
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 190
Provider Second Line Business Mailing Address:
16 PENNSYLVANIA AVE
Provider Business Mailing Address City Name:
MATAMORAS
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18336
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-491-4145
Provider Business Mailing Address Fax Number:
570-491-5119

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16 PENNSYLVANIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MATAMORAS
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-491-4145
Provider Business Practice Location Address Fax Number:
570-491-5119
Provider Enumeration Date:
06/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ALBERTO
Authorized Official First Name:
PAMELA
Authorized Official Middle Name:
LOUISE
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
570-491-4145

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DS035287 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0106X , with the licence number: DS020813L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223P0106X , with the licence number: DS030426L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





Copyright © 2007-2024 www.npivalidator.com