Healthcare Provider Details

I. General information

NPI: 1700839008
Provider Name (Legal Business Name): BEECHMONT ANESTHESIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 05/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 MOISEY DRIVE SUITE 204
HAZLETON PA
18202
US

IV. Provider business mailing address

PO BOX 70
MOUNTAIN TOP PA
18707
US

V. Phone/Fax

Practice location:
  • Phone: 570-501-6860
  • Fax: 570-501-6869
Mailing address:
  • Phone: 570-501-6860
  • Fax: 570-501-6869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier1013091350001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: RENEE STROUP
Title or Position: BILLING CREDENTIALING MANAGER
Credential:
Phone: 570-501-6863