Healthcare Provider Details

I. General information

NPI: 1043375702
Provider Name (Legal Business Name): HAZLETON ENDOSCOPY CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2006
Last Update Date: 12/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 PARK PLACE
HAZLE TOWNSHIP PA
18202-9394
US

IV. Provider business mailing address

10 PARK PLACE
HAZLE TOWNSHIP PA
18202-9394
US

V. Phone/Fax

Practice location:
  • Phone: 570-454-1400
  • Fax: 570-454-2144
Mailing address:
  • Phone: 570-454-1400
  • Fax: 570-454-2144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number14601501
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2678733
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerAETNA
# 2
Identifier1007294940003
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: DR. YOUNG KUL YOO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 570-454-1400