Provider Demographics
NPI:1851469738
Name:LACKAWANNA SURGERY CENTER LLC
Entity Type:Organization
Organization Name:LACKAWANNA SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:FRATTALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-346-7900
Mailing Address - Street 1:PO BOX 3445
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18505-0445
Mailing Address - Country:US
Mailing Address - Phone:570-504-8100
Mailing Address - Fax:570-504-8106
Practice Address - Street 1:415 ADAMS AVENUE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510
Practice Address - Country:US
Practice Address - Phone:570-504-8100
Practice Address - Fax:570-504-8106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA21511501261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA112119Medicare PIN