Provider Demographics
NPI:1487659744
Name:EAGEN, JEREMIAH W (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:W
Last Name:EAGEN
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 1:802 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18510-1038
Mailing Address - Country:US
Mailing Address - Phone:570-348-0360
Mailing Address - Fax:570-348-0362
Practice Address - Street 1:802 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-1038
Practice Address - Country:US
Practice Address - Phone:570-348-0360
Practice Address - Fax:570-348-0362
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-021443-E207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1187399Medicaid
PA815507OtherFIRST PRIORITY
PA851436OtherBLUE SHEILD
PA1187399Medicaid