Provider Demographics
NPI:1790961274
Name:LUZERNE COUNTY GENERAL PRACTICE ASSOCIATES LLC
Entity Type:Organization
Organization Name:LUZERNE COUNTY GENERAL PRACTICE ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:J
Authorized Official - Last Name:STUKA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:570-655-2959
Mailing Address - Street 1:1701 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:EXETER
Mailing Address - State:PA
Mailing Address - Zip Code:18643-1491
Mailing Address - Country:US
Mailing Address - Phone:570-655-2959
Mailing Address - Fax:570-655-9213
Practice Address - Street 1:1701 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:EXETER
Practice Address - State:PA
Practice Address - Zip Code:18643-1491
Practice Address - Country:US
Practice Address - Phone:570-655-2959
Practice Address - Fax:570-655-9213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-15
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS003170L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1999580OtherHIGHMARK BLUE SHIELD
PA1289OtherFIRST PRIORITY HEALTH
PA1999580OtherFIRST PRIORITY LIFE INSURANCE
PA1289OtherFIRST PRIORITY HEALTH