1104051200 NPI number — DR. KRISTA BOTT M.D.

Table of content: DR. KRISTA BOTT M.D. (NPI 1104051200)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104051200 NPI number — DR. KRISTA BOTT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOTT
Provider First Name:
KRISTA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1104051200
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/04/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
206 E BROWN ST
Provider Second Line Business Mailing Address:
POCONO HEALTH SYSTEM - PROFESSIONAL CENTER
Provider Business Mailing Address City Name:
EAST STROUDSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18301-3006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-420-4919
Provider Business Mailing Address Fax Number:
570-426-2643

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 COMMERCE BLVD
Provider Second Line Business Practice Location Address:
3RD FLOOR
Provider Business Practice Location Address City Name:
STROUDSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18360-6214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-426-6070
Provider Business Practice Location Address Fax Number:
570-422-8091
Provider Enumeration Date:
05/19/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  MT194819 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: MD451073 , 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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