Provider Demographics
NPI:1932319639
Name:SOLI F TAVARIA MC PC
Entity Type:Organization
Organization Name:SOLI F TAVARIA MC PC
Other - Org Name:AMZ LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SOLI
Authorized Official - Middle Name:F
Authorized Official - Last Name:TAVARIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-544-6424
Mailing Address - Street 1:105 N DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:MINERSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17954
Mailing Address - Country:US
Mailing Address - Phone:570-544-6424
Mailing Address - Fax:570-544-2734
Practice Address - Street 1:105 N DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:MINERSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17954
Practice Address - Country:US
Practice Address - Phone:570-544-6424
Practice Address - Fax:570-544-2734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA000877291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007495120001Medicaid
PA39D0657443OtherCLIA CERTIFICATION