Provider Demographics
NPI: | 1790811172 |
---|---|
Name: | GEISINGER SOUTH WILKES BARRE |
Entity Type: | Organization |
Organization Name: | GEISINGER SOUTH WILKES BARRE |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | VP |
Authorized Official - Prefix: | |
Authorized Official - First Name: | BARBARA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | TAPSCOTT |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 570-214-7993 |
Mailing Address - Street 1: | 5 LAKEVIEW DR |
Mailing Address - Street 2: | |
Mailing Address - City: | MOOSIC |
Mailing Address - State: | PA |
Mailing Address - Zip Code: | 18705 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 570-241-5642 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 25 CHURCH STREET |
Practice Address - Street 2: | |
Practice Address - City: | WILKES BARRE |
Practice Address - State: | PA |
Practice Address - Zip Code: | 18765 |
Practice Address - Country: | US |
Practice Address - Phone: | 570-214-9763 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | GEISINGER SOUTH WILKES BARRE |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2007-02-27 |
Last Update Date: | 2008-03-18 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261Q00000X | Ambulatory Health Care Facilities | Clinic/Center |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
PA | 390169 | Medicare Oscar/Certification |