Provider Demographics
NPI:1982791117
Name:LACKAWANNA VALLEY DERMATOLOGY ASSOCIATES LIMITED
Entity Type:Organization
Organization Name:LACKAWANNA VALLEY DERMATOLOGY ASSOCIATES LIMITED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:A
Authorized Official - Last Name:SEVERS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:570-961-5522
Mailing Address - Street 1:327 N WASHINGTON AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18503-1549
Mailing Address - Country:US
Mailing Address - Phone:570-961-5522
Mailing Address - Fax:570-207-5579
Practice Address - Street 1:327 N WASHINGTON AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18503-1549
Practice Address - Country:US
Practice Address - Phone:570-961-5522
Practice Address - Fax:570-207-5579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA133368Medicare ID - Type Unspecified
PA0011156200011Medicaid