Healthcare Provider Details

I. General information

NPI: 1497765234
Provider Name (Legal Business Name): MOUNTAIN AREA HEALTHCARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 06/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 E BROAD ST
HAZLETON PA
18201-6520
US

IV. Provider business mailing address

23 E BROAD ST
HAZLETON PA
18201-6520
US

V. Phone/Fax

Practice location:
  • Phone: 570-454-8204
  • Fax: 570-459-0099
Mailing address:
  • Phone: 570-454-8204
  • Fax: 570-459-0099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MISS LISA M MATRICCINO
Title or Position: OFFICE MANAGER
Credential:
Phone: 570-454-8204