Healthcare Provider Details

I. General information

NPI: 1407056732
Provider Name (Legal Business Name): JOSEPH P. CHOLLAK, JR., M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2007
Last Update Date: 11/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 WYOMING AVE
FORTY FORT PA
18704-3966
US

IV. Provider business mailing address

950 WYOMING AVE
FORTY FORT PA
18704-3966
US

V. Phone/Fax

Practice location:
  • Phone: 570-287-7704
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD-011393-E
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberMD-011393-E
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA-003120-L
License Number StatePA

VIII. Authorized Official

Name: MRS. SHELLY MARANSKY
Title or Position: ADMIN ASSISTANT
Credential:
Phone: 570-287-7707