Provider Demographics
NPI:1568407583
Name:FORMANEK, GREGORY A (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:FORMANEK
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:PO BOX 827658
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-7658
Mailing Address - Country:US
Mailing Address - Phone:570-420-4951
Mailing Address - Fax:570-476-3754
Practice Address - Street 1:205 E BROWN ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-3006
Practice Address - Country:US
Practice Address - Phone:570-420-2188
Practice Address - Fax:570-421-3493
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101232517207RH0003X
PAMD041860L207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06778OtherGROUP PTAN
VAC06778OtherGROUP PTAN
VAC06700Medicare PIN
VA830000167Medicare PIN
VACG1132Medicare PIN