Provider Demographics
NPI:1508143074
Name:SCRANTON QUINCY CLINIC COMPANY LLC
Entity Type:Organization
Organization Name:SCRANTON QUINCY CLINIC COMPANY LLC
Other - Org Name:PHYSICIANS HEALTH ALLIANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR DIRECTOR PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-892-9815
Mailing Address - Street 1:4000 MERIDIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-6325
Mailing Address - Country:US
Mailing Address - Phone:615-465-7000
Mailing Address - Fax:615-465-6877
Practice Address - Street 1:748 QUINCY AVE
Practice Address - Street 2:SUITE 1A
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-1739
Practice Address - Country:US
Practice Address - Phone:570-347-9600
Practice Address - Fax:570-342-0681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-10
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102669377-0001Medicaid
PA102669377-0001Medicaid