Provider Demographics
NPI:1518916758
Name:MOUNTAIN LAUREL SURGERY CENTER L.L.C.
Entity Type:Organization
Organization Name:MOUNTAIN LAUREL SURGERY CENTER L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-253-3391
Mailing Address - Street 1:1860 FAIR AVE STE B
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-2182
Mailing Address - Country:US
Mailing Address - Phone:570-253-6688
Mailing Address - Fax:570-253-1811
Practice Address - Street 1:1860 FAIR AVE STE B
Practice Address - Street 2:
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431-2182
Practice Address - Country:US
Practice Address - Phone:570-253-6688
Practice Address - Fax:570-253-1811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-07
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA821485OtherFIRST PRIORITY
PAP00369599OtherRAILROAD MEDICARE PROVIDE
PA991085OtherBLUE CROSS
PA104905Medicare PIN