Provider Demographics
NPI:1669669859
Name:NICHOLAS DODGE, M.D., P.C.
Entity Type:Organization
Organization Name:NICHOLAS DODGE, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DODGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-344-5115
Mailing Address - Street 1:121 VOSBURG LN
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-2717
Mailing Address - Country:US
Mailing Address - Phone:570-344-5115
Mailing Address - Fax:570-344-2123
Practice Address - Street 1:414 E DRINKER ST STE 204
Practice Address - Street 2:
Practice Address - City:DUNMORE
Practice Address - State:PA
Practice Address - Zip Code:18512-2469
Practice Address - Country:US
Practice Address - Phone:570-344-5115
Practice Address - Fax:570-344-2123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD054271L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1669669859OtherNPI
PA616633OtherFIRST PRIORITY LIFE
PA616633OtherAETNA
PA002981OtherFIRST PRIORITY HMO
PADG7762OtherRAILROAD MEDICARE
PA0763711000OtherBLUE CARE / BLUE SHIELD
PA0015086460006Medicaid
PA616633OtherBLUE SHIELD PA
PA020395000OtherBLACK LUNG
PA0015086460006Medicaid