Provider Demographics
NPI:1124296314
Name:DR MARY A WALTERS
Entity type:Organization
Organization Name:DR MARY A WALTERS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:570-288-9444
Mailing Address - Street 1:1174 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:FORTY FORT
Mailing Address - State:PA
Mailing Address - Zip Code:18704-4016
Mailing Address - Country:US
Mailing Address - Phone:570-288-9444
Mailing Address - Fax:570-331-7543
Practice Address - Street 1:1174 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:FORTY FORT
Practice Address - State:PA
Practice Address - Zip Code:18704-4016
Practice Address - Country:US
Practice Address - Phone:570-288-9444
Practice Address - Fax:570-331-7543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA072962OtherFIRST PRIORITY HEALTH
PA1659387678OtherINDV NPI TYPE 1
PAWA181952OtherMEDICARE
PA181952OtherBLUE CROSS BLUE SHIELD