Healthcare Provider Details

I. General information

NPI: 1679560403
Provider Name (Legal Business Name): PAIN SPECIALISTS OF GREATER LEHIGH VALLEY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 S CEDAR CREST BLVD SUITE #307
ALLENTOWN PA
18103-6369
US

IV. Provider business mailing address

1245 S CEDAR CREST BLVD SUITE #301
ALLENTOWN PA
18103-6258
US

V. Phone/Fax

Practice location:
  • Phone: 610-402-1757
  • Fax: 610-402-9089
Mailing address:
  • Phone: 610-402-1757
  • Fax: 610-402-9089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number StatePA

VIII. Authorized Official

Name: LORETTA KOWALICK
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 610-402-1757