Healthcare Provider Details

I. General information

NPI: 1154855898
Provider Name (Legal Business Name): ENDOCRINOLOGY CLINIC P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2017
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 N CHURCH ST 200 HAZLETON PROFESSIONAL PLAZA
HAZLE TOWNSHIP PA
18202-1480
US

IV. Provider business mailing address

1090 N CHURCH ST 200 HAZLETON PROFESSIONAL PLAZA
HAZLE TOWNSHIP PA
18202-1480
US

V. Phone/Fax

Practice location:
  • Phone: 570-455-0100
  • Fax: 570-455-0177
Mailing address:
  • Phone: 570-455-0100
  • Fax: 570-455-0177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberMD438286
License Number StatePA

VIII. Authorized Official

Name: DR. AYSE KARCA MOHYUDDIN
Title or Position: PRESIDENT
Credential: MD
Phone: 570-455-0100