Provider Demographics
NPI:1144251745
Name:POCONO ADULT & PEDIATRIC MEDICAL GROUP LLC
Entity type:Organization
Organization Name:POCONO ADULT & PEDIATRIC MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SOLIBE
Authorized Official - Middle Name:CHIKAODILI
Authorized Official - Last Name:UFONDU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-476-4161
Mailing Address - Street 1:302 E BROWN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-3010
Mailing Address - Country:US
Mailing Address - Phone:570-476-4161
Mailing Address - Fax:570-476-9954
Practice Address - Street 1:302 E BROWN ST
Practice Address - Street 2:SUITE A
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-3010
Practice Address - Country:US
Practice Address - Phone:570-476-4161
Practice Address - Fax:570-476-9954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD062320L208000000X
PAMD062479L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001318932OtherHIGHMARK