Provider Demographics
NPI:1043580087
Name:EASTERN POCONOS INTERNAL MEDICINE
Entity Type:Organization
Organization Name:EASTERN POCONOS INTERNAL MEDICINE
Other - Org Name:SETHURAMAN MUTHIAH, MD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:SETHURAMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MUTHIAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-424-2025
Mailing Address - Street 1:6977 ROUTE 611 OLYMPIA PLAZA
Mailing Address - Street 2:
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360-9166
Mailing Address - Country:US
Mailing Address - Phone:570-424-2025
Mailing Address - Fax:570-424-2028
Practice Address - Street 1:6977 ROUTE 611 OLYMPIA PLAZA
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-9166
Practice Address - Country:US
Practice Address - Phone:570-424-2025
Practice Address - Fax:570-424-2028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD062954L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001663400Medicaid
PAG57227Medicare UPIN