Healthcare Provider Details

I. General information

NPI: 1730162678
Provider Name (Legal Business Name): PEDIATRIC PRACTICES OF NORTHEASTERN PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1837 FAIR AVE
HONESDALE PA
18431-2121
US

IV. Provider business mailing address

1837 FAIR AVE
HONESDALE PA
18431-2121
US

V. Phone/Fax

Practice location:
  • Phone: 570-253-5838
  • Fax: 570-253-1245
Mailing address:
  • Phone: 570-253-5838
  • Fax: 570-253-1245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT MORTON
Title or Position: PARTNER
Credential: M.D.
Phone: 570-253-5838