1740272871 NPI number — WYOMING VALLEY RADIATION MEDICINE ASSOCIATES P C

Table of content: (NPI 1740272871)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740272871 NPI number — WYOMING VALLEY RADIATION MEDICINE ASSOCIATES P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WYOMING VALLEY RADIATION MEDICINE 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:
Provider Other Organization Name Type Code:
6
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:
1740272871
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
50 ROOSEVELT TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILKES BARRE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18702-3517
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-822-9822
Provider Business Mailing Address Fax Number:
570-822-7955

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 ROOSEVELT TER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILKES BARRE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18702-3517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-822-9822
Provider Business Practice Location Address Fax Number:
570-822-7955
Provider Enumeration Date:
08/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ROSTOCK
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
A
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
570-822-9822

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QX0203X , with the licence number: AC02-40449 , 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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