Provider Demographics
NPI:1942211248
Name:NORTHEASTERN GASTROENTEROLOGY ASSOCIATES, PC
Entity Type:Organization
Organization Name:NORTHEASTERN GASTROENTEROLOGY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:DEWITT
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-253-3991
Mailing Address - Street 1:1860 FAIR AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-2108
Mailing Address - Country:US
Mailing Address - Phone:570-253-3391
Mailing Address - Fax:570-253-1811
Practice Address - Street 1:1860 FAIR AVE
Practice Address - Street 2:SUITE A
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431-2108
Practice Address - Country:US
Practice Address - Phone:570-253-3391
Practice Address - Fax:570-253-1811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016721410006Medicaid
PA804251OtherFIRST PRIORITY
0450817000OtherAMERIHEALTH & INDEP BS
2400697OtherGHI
PA66362OtherBLUE SHIELD
PA77790OtherBLUE SHIELD 65 SPECIAL
PA0016721410006Medicaid
2400697OtherGHI