Provider Demographics
NPI:1881253011
Name:MAIN STREET PEDIATRICS OF GREATER SCRANTON
Entity type:Organization
Organization Name:MAIN STREET PEDIATRICS OF GREATER SCRANTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR.
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDONOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-291-4180
Mailing Address - Street 1:247 MAIN ST # PA
Mailing Address - Street 2:
Mailing Address - City:DICKSON CITY
Mailing Address - State:PA
Mailing Address - Zip Code:18519-1641
Mailing Address - Country:US
Mailing Address - Phone:570-291-4180
Mailing Address - Fax:570-586-3953
Practice Address - Street 1:247 MAIN ST # PA
Practice Address - Street 2:
Practice Address - City:DICKSON CITY
Practice Address - State:PA
Practice Address - Zip Code:18519-1641
Practice Address - Country:US
Practice Address - Phone:570-291-4180
Practice Address - Fax:570-586-3953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011992910003Medicaid