Provider Demographics
NPI:1407845191
Name:EMANUELSON, RICHARD G (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:G
Last Name:EMANUELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 MEADE ST
Mailing Address - Street 2:
Mailing Address - City:DUNMORE
Mailing Address - State:PA
Mailing Address - Zip Code:18512-3169
Mailing Address - Country:US
Mailing Address - Phone:570-342-3675
Mailing Address - Fax:570-342-3316
Practice Address - Street 1:1100 MEADE ST
Practice Address - Street 2:
Practice Address - City:DUNMORE
Practice Address - State:PA
Practice Address - Zip Code:18512-3169
Practice Address - Country:US
Practice Address - Phone:570-342-3675
Practice Address - Fax:570-342-3316
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD035339E207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010414380005Medicaid
PA0010414380005Medicaid
B33740Medicare UPIN