Provider Demographics
NPI:1407056732
Name:JOSEPH P. CHOLLAK, JR., M.D.
Entity Type:Organization
Organization Name:JOSEPH P. CHOLLAK, JR., M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARANSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-287-7707
Mailing Address - Street 1:950 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:FORTY FORT
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3966
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:950 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:FORTY FORT
Practice Address - State:PA
Practice Address - Zip Code:18704-3966
Practice Address - Country:US
Practice Address - Phone:570-287-7704
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-011393-E207Q00000X, 207QG0300X
PAMA-003120-L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0008576980004Medicaid
PA0008576980004Medicaid
087244Medicare PIN