Provider Demographics
NPI:1477526655
Name:NORTHEAST DERMATOPATHOLOGY INSTITUTE
Entity Type:Organization
Organization Name:NORTHEAST DERMATOPATHOLOGY INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:SZYMANSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-586-4400
Mailing Address - Street 1:405 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-1542
Mailing Address - Country:US
Mailing Address - Phone:570-586-4400
Mailing Address - Fax:570-587-5531
Practice Address - Street 1:405 S STATE ST
Practice Address - Street 2:
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411-1542
Practice Address - Country:US
Practice Address - Phone:570-586-4400
Practice Address - Fax:570-587-5531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA029481291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00238091OtherRAILROAD MEDICARE
PA1014008140001Medicaid
PA093591Medicare PIN