Provider Demographics
NPI:1942350087
Name:SAMIR B PANCHOLY LLC
Entity Type:Organization
Organization Name:SAMIR B PANCHOLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:B
Authorized Official - Last Name:PANCHOLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-876-6140
Mailing Address - Street 1:286 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLYPHANT
Mailing Address - State:PA
Mailing Address - Zip Code:18447-2317
Mailing Address - Country:US
Mailing Address - Phone:570-876-6140
Mailing Address - Fax:570-872-7776
Practice Address - Street 1:286 MAIN ST
Practice Address - Street 2:
Practice Address - City:OLYPHANT
Practice Address - State:PA
Practice Address - Zip Code:18447-2317
Practice Address - Country:US
Practice Address - Phone:570-876-6140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD045919L207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA=========OtherTAX ID NUMBER