Provider Demographics
NPI:1902183304
Name:SCRANTON QUINCY CLINIC COMPANY LLC
Entity Type:Organization
Organization Name:SCRANTON QUINCY CLINIC COMPANY LLC
Other - Org Name:PHYSICIANS HEALTH ALLIANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:THORN
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-892-9813
Mailing Address - Street 1:PO BOX 689022
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-9022
Mailing Address - Country:US
Mailing Address - Phone:877-309-5312
Mailing Address - Fax:615-465-2877
Practice Address - Street 1:748 QUINCY AVE
Practice Address - Street 2:SUITE 1A
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-1739
Practice Address - Country:US
Practice Address - Phone:570-347-9600
Practice Address - Fax:570-342-0681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-14
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102669377-0002Medicaid
PA233475Medicare PIN