Provider Demographics
NPI:1235284837
Name:SHAMOKIN DAM HEALTH CENTER PC
Entity Type:Organization
Organization Name:SHAMOKIN DAM HEALTH CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:DUNIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:570-743-4333
Mailing Address - Street 1:3166 NORTH OLD TRAIL
Mailing Address - Street 2:
Mailing Address - City:SHAMOKIN DAM
Mailing Address - State:PA
Mailing Address - Zip Code:17876-9409
Mailing Address - Country:US
Mailing Address - Phone:570-743-4333
Mailing Address - Fax:570-743-6012
Practice Address - Street 1:3166 NORTH OLD TRAIL
Practice Address - Street 2:
Practice Address - City:SHAMOKIN DAM
Practice Address - State:PA
Practice Address - Zip Code:17876-9409
Practice Address - Country:US
Practice Address - Phone:570-743-4333
Practice Address - Fax:570-743-6012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019697320001Medicaid
808250R2TMedicare PIN
072997Medicare PIN
107809R2TMedicare PIN
PA446725R2TMedicare PIN