Provider Demographics
NPI:1457381113
Name:NORTHEASTERN SURGICAL SPECIALTY GROUP INC
Entity Type:Organization
Organization Name:NORTHEASTERN SURGICAL SPECIALTY GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:KOPEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-283-2323
Mailing Address - Street 1:190 WELLES ST
Mailing Address - Street 2:
Mailing Address - City:FORTY FORT
Mailing Address - State:PA
Mailing Address - Zip Code:18704-4968
Mailing Address - Country:US
Mailing Address - Phone:570-283-2323
Mailing Address - Fax:570-283-1290
Practice Address - Street 1:190 WELLES ST
Practice Address - Street 2:
Practice Address - City:FORTY FORT
Practice Address - State:PA
Practice Address - Zip Code:18704-4968
Practice Address - Country:US
Practice Address - Phone:570-283-2323
Practice Address - Fax:570-283-1290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA190358OtherHIGHMARK BLUE SHIELD
PA61472OtherAETNA US HEALTHCARE
PA072571OtherFIRST PRIORITY
PA25126OtherHEALTH AMERICA
PA7227OtherGEISINGER HEALTH PLAN
PA876894OtherCOVENTRY
PA88381OtherUNITED HEALTHCARE
PAB34409OtherSTERLING
PA0010907280003Medicaid
PA072571OtherFIRST PRIORITY
PA25126OtherHEALTH AMERICA