Provider Demographics
NPI:1780709907
Name:ENDOCRINE SPECIALTY GROUP INC.
Entity type:Organization
Organization Name:ENDOCRINE SPECIALTY GROUP INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:FELLERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-714-9322
Mailing Address - Street 1:644 GIBSON AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-5320
Mailing Address - Country:US
Mailing Address - Phone:570-283-4806
Mailing Address - Fax:570-283-3044
Practice Address - Street 1:183 MARKET ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5444
Practice Address - Country:US
Practice Address - Phone:570-714-9322
Practice Address - Fax:570-714-8750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD010836E207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PW1376648444OtherINDIVIDUAL NPI NUMBER
PRB33182Medicare UPIN
PAFEO18700Medicare ID - Type Unspecified