Provider Demographics
NPI:1114953429
Name:NORTHEAST PA NEURO-SPINE, P.C.
Entity Type:Organization
Organization Name:NORTHEAST PA NEURO-SPINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:J
Authorized Official - Last Name:HLAVAC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-558-3540
Mailing Address - Street 1:3 W OLIVE ST
Mailing Address - Street 2:STE 201
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18508-2572
Mailing Address - Country:US
Mailing Address - Phone:570-969-0663
Mailing Address - Fax:570-969-9697
Practice Address - Street 1:414 E DRINKER ST
Practice Address - Street 2:
Practice Address - City:DUNMORE
Practice Address - State:PA
Practice Address - Zip Code:18512-2469
Practice Address - Country:US
Practice Address - Phone:570-558-3540
Practice Address - Fax:570-558-3547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1832581OtherBLUE SHIELD GROUP NUMBER
PA1832581OtherBLUE SHIELD GROUP NUMBER