Healthcare Provider Details

I. General information

NPI: 1063621233
Provider Name (Legal Business Name): BACK MOUNTAIN PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 MEMORIAL HIGHWAY
DALLAS PA
18612
US

IV. Provider business mailing address

550 MEMORIAL HIGHWAY SUITE 1
DALLAS PA
18612
US

V. Phone/Fax

Practice location:
  • Phone: 570-675-7955
  • Fax: 570-675-7882
Mailing address:
  • Phone: 570-675-7955
  • Fax: 570-675-7882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number022874
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD024845E
License Number StatePA

VIII. Authorized Official

Name: DR. JOAN E GREULICK
Title or Position: OWNER
Credential: MD
Phone: 570-675-7955