1144251745 NPI number — POCONO ADULT & PEDIATRIC MEDICAL GROUP LLC

Table of content: (NPI 1144251745)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144251745 NPI number — POCONO ADULT & PEDIATRIC MEDICAL GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POCONO ADULT & PEDIATRIC MEDICAL GROUP LLC
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:
1144251745
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
302 E BROWN ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
EAST STROUDSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18301-3010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-476-4161
Provider Business Mailing Address Fax Number:
570-476-9954

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
302 E BROWN ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
EAST STROUDSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18301-3010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-476-4161
Provider Business Practice Location Address Fax Number:
570-476-9954
Provider Enumeration Date:
07/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
UFONDU
Authorized Official First Name:
SOLIBE
Authorized Official Middle Name:
CHIKAODILI
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
570-476-4161

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD062479L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: MD062320L , 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)

  • Identifier: 001318932 . This is a "HIGHMARK" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com