Provider Demographics
NPI:1851387013
Name:STRP FACULTY SERVICE
Entity Type:Organization
Organization Name:STRP FACULTY SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ELIDORO
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIMERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-941-0630
Mailing Address - Street 1:746 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18510-1624
Mailing Address - Country:US
Mailing Address - Phone:570-343-2383
Mailing Address - Fax:570-963-6133
Practice Address - Street 1:640 MADISON AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-1607
Practice Address - Country:US
Practice Address - Phone:570-961-5670
Practice Address - Fax:570-961-5991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0663952Medicaid
SC152577Medicare ID - Type Unspecified
B39996Medicare UPIN