Provider Demographics
NPI:1194834606
Name:SLEEP DISORDER CENTER OF WYOMING VALLEY
Entity Type:Organization
Organization Name:SLEEP DISORDER CENTER OF WYOMING VALLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:POTORSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-288-5441
Mailing Address - Street 1:610 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3702
Mailing Address - Country:US
Mailing Address - Phone:570-288-5441
Mailing Address - Fax:570-288-5842
Practice Address - Street 1:1065 HIGHWAY 315
Practice Address - Street 2:SUITE 202
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-6941
Practice Address - Country:US
Practice Address - Phone:570-829-6900
Practice Address - Fax:570-829-0122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD034081E207RS0012X
261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Single Specialty
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder DiagnosticGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
076210Medicare ID - Type Unspecified