Provider Demographics
NPI:1417914979
Name:IMBROGNO, MICHAEL STEVEN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:STEVEN
Last Name:IMBROGNO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1736
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18703-1736
Mailing Address - Country:US
Mailing Address - Phone:570-822-7070
Mailing Address - Fax:570-822-9468
Practice Address - Street 1:3 OAK CTR
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-7338
Practice Address - Country:US
Practice Address - Phone:570-822-7070
Practice Address - Fax:570-822-9468
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD037262E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
B42177Medicare UPIN