1538646591 NPI number — WYOMING VALLEY FOOT ASSOCIATES P C

Table of content: (NPI 1538646591)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538646591 NPI number — WYOMING VALLEY FOOT ASSOCIATES P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WYOMING VALLEY FOOT ASSOCIATES P C
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:
DR LEON A ELLMAN, PC
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:
1538646591
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
421 MARKET ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGSTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18704-5418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-283-0220
Provider Business Mailing Address Fax Number:
570-283-1707

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
457 N MAIN ST STE 105
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:
18640-2185
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-299-2953
Provider Business Practice Location Address Fax Number:
570-569-2117
Provider Enumeration Date:
07/23/2018

Additional Information

Authorized Official

Authorized Official Last Name:
TOOLE
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
570-283-0220

Provider Taxonomy Codes

  • Taxonomy code: 213ES0131X , with the licence number:  SC002926L , 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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