1497960199 NPI number — GEISINGER WYOMING VALLEY DBA MEDIC 303

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 1497960199 NPI number — GEISINGER WYOMING VALLEY DBA MEDIC 303

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEISINGER WYOMING VALLEY DBA MEDIC 303
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:
1497960199
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
205 GRANDVIEW AVE
Provider Second Line Business Mailing Address:
SUITE 211
Provider Business Mailing Address City Name:
CAMP HILL
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17011-1708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-972-4732
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
57 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PITTSTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18640-1915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-972-4732
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MULL
Authorized Official First Name:
CINDY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
SYSTEM DIRECTOR ENROLLMENTS
Authorized Official Telephone Number:
570-271-6603

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  06059 , 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)





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