Provider Demographics
NPI:1710907043
Name:BUCKTAIL MEDICAL CENTER
Entity Type:Organization
Organization Name:BUCKTAIL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-923-1000
Mailing Address - Street 1:1001 PINE ST
Mailing Address - Street 2:
Mailing Address - City:RENOVO
Mailing Address - State:PA
Mailing Address - Zip Code:17764-1618
Mailing Address - Country:US
Mailing Address - Phone:570-923-1019
Mailing Address - Fax:570-923-1650
Practice Address - Street 1:1001 PINE ST
Practice Address - Street 2:
Practice Address - City:RENOVO
Practice Address - State:PA
Practice Address - Zip Code:17764-1618
Practice Address - Country:US
Practice Address - Phone:570-923-1019
Practice Address - Fax:570-923-1650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA549601261Q00000X, 261QC0050X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC0050XAmbulatory Health Care FacilitiesClinic/CenterCritical Access Hospital
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007644390003Medicaid
PA391304Medicare Oscar/Certification
PA137601Medicare PIN