Provider Demographics
NPI:1629196043
Name:P.BOONSWANG MD
Entity Type:Organization
Organization Name:P.BOONSWANG MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PRICHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOONSWANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-252-2229
Mailing Address - Street 1:2358 GRUVER AVE
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18045-2808
Mailing Address - Country:US
Mailing Address - Phone:610-252-2229
Mailing Address - Fax:610-252-8468
Practice Address - Street 1:2358 GRUVER AVE
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18045-2808
Practice Address - Country:US
Practice Address - Phone:610-252-2229
Practice Address - Fax:610-252-8468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006479210002Medicaid
NJ4961200Medicaid
NJ4961200Medicaid