Provider Demographics
NPI:1467547208
Name:PENN NEUROLOGY AND PSYCHIATRY ASSOCIATES, PC
Entity Type:Organization
Organization Name:PENN NEUROLOGY AND PSYCHIATRY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IQBAL
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-474-6001
Mailing Address - Street 1:10 1/2 SOUTH MOUNTAIN BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN TOP
Mailing Address - State:PA
Mailing Address - Zip Code:18707
Mailing Address - Country:US
Mailing Address - Phone:570-474-6001
Mailing Address - Fax:886-269-6004
Practice Address - Street 1:10 1/2 SOUTH MOUNTAIN BOULEVARD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN TOP
Practice Address - State:PA
Practice Address - Zip Code:18707
Practice Address - Country:US
Practice Address - Phone:570-474-6001
Practice Address - Fax:886-269-6004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD065153L2084N0400X
PAMD052377L2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1011631480001Medicaid
PA083044Medicare ID - Type UnspecifiedGROUP NUMBER
PA538859S5CMedicare ID - Type UnspecifiedDR. IQBAL INDIVIDUAL PROV
PA1011631480001Medicaid