Provider Demographics
NPI:1265458988
Name:WYOMING VALLEY PATHOLOGY ASSOCIATES
Entity Type:Organization
Organization Name:WYOMING VALLEY PATHOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOTCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-714-5544
Mailing Address - Street 1:575 N RIVER ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18764-0999
Mailing Address - Country:US
Mailing Address - Phone:570-829-8111
Mailing Address - Fax:
Practice Address - Street 1:575 N RIVER ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18764-0999
Practice Address - Country:US
Practice Address - Phone:570-829-8111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018087870002Medicaid
PA0018087870002Medicaid