Provider Demographics
NPI:1447580584
Name:PENNSYLVANIA ASSOCIATES, LLC
Entity Type:Organization
Organization Name:PENNSYLVANIA ASSOCIATES, LLC
Other - Org Name:MOUNT POCONO MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR OF CONTRACT MGMT
Authorized Official - Prefix:
Authorized Official - First Name:ROBYN
Authorized Official - Middle Name:
Authorized Official - Last Name:TANIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-533-8762
Mailing Address - Street 1:1317 ROUTE 73 STE 200
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-2202
Mailing Address - Country:US
Mailing Address - Phone:856-439-6111
Mailing Address - Fax:
Practice Address - Street 1:663 MOUNT POCONO BLVD
Practice Address - Street 2:UNIT 3
Practice Address - City:MOUNT POCONO
Practice Address - State:PA
Practice Address - Zip Code:18344
Practice Address - Country:US
Practice Address - Phone:570-839-7246
Practice Address - Fax:570-839-7248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-13
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA457036261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA457036OtherPA DEPARTMENT OF HEALTH LICENSE NUMBER