Provider Demographics
NPI:1578895538
Name:PEDIATRIC PRACTICES OF NORTHEASTERN PA
Entity Type:Organization
Organization Name:PEDIATRIC PRACTICES OF NORTHEASTERN PA
Other - Org Name:PEDIATRIC PRACTICES OF NORTHEASTERN PA
Other - Org Type:Other Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MORTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-253-5838
Mailing Address - Street 1:1837 FAIR AVE
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-2121
Mailing Address - Country:US
Mailing Address - Phone:570-488-9550
Mailing Address - Fax:570-488-9553
Practice Address - Street 1:27B WOODLANDS DR
Practice Address - Street 2:
Practice Address - City:WAYMART
Practice Address - State:PA
Practice Address - Zip Code:18472-9366
Practice Address - Country:US
Practice Address - Phone:570-448-9550
Practice Address - Fax:570-488-9553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-02
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA39-3906OtherCMS CERTIFICATION NUMBER
PA1007422260018Medicaid