Provider Demographics
NPI:1326277492
Name:POCONO PODIATRY AND WOUND CARE, LLC.
Entity Type:Organization
Organization Name:POCONO PODIATRY AND WOUND CARE, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TANJILA
Authorized Official - Middle Name:
Authorized Official - Last Name:MATIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:570-431-0788
Mailing Address - Street 1:296 E BROWN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-3011
Mailing Address - Country:US
Mailing Address - Phone:570-431-0788
Mailing Address - Fax:
Practice Address - Street 1:296 E BROWN ST
Practice Address - Street 2:SUITE B
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-3011
Practice Address - Country:US
Practice Address - Phone:215-681-8057
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-09
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC005819213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101945964Medicaid
PAV09606Medicare UPIN
PA11536Medicare PIN
PA101945964Medicaid