Healthcare Provider Details

I. General information

NPI: 1881916989
Provider Name (Legal Business Name): LAKE REGION URGENT CARE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2010
Last Update Date: 07/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 SPRUCE ST SUITE 201
HAWLEY PA
18428-1149
US

IV. Provider business mailing address

PO BOX 1733
KINGSTON PA
18704-0733
US

V. Phone/Fax

Practice location:
  • Phone: 570-390-4545
  • Fax: 570-390-4546
Mailing address:
  • Phone: 570-390-4545
  • Fax: 570-390-4546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ROMAN W MATLAGA
Title or Position: MEDICAL DIRECTOR
Credential: D.O.
Phone: 570-390-4545