Healthcare Provider Details

I. General information

NPI: 1083911242
Provider Name (Legal Business Name): NORTHEASTERN PENNSYLVANIA HEALTH CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2011
Last Update Date: 02/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 E BROAD ST PATIENT ACCOUNTS
HAZLETON PA
18201-6835
US

IV. Provider business mailing address

50 MOISEY DR SUITE 208
HAZLE TOWNSHIP PA
18202-9297
US

V. Phone/Fax

Practice location:
  • Phone: 570-501-4700
  • Fax: 570-501-4803
Mailing address:
  • Phone: 570-501-6800
  • Fax: 570-501-6805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberMD017859E
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier1780748152
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerNORTHEASTERN PENNSYLVANIA HEALTH CORPORATION NPI

VIII. Authorized Official

Name: WILLIAM BAUER
Title or Position: CFO
Credential:
Phone: 570-501-8293