Healthcare Provider Details

I. General information

NPI: 1801266879
Provider Name (Legal Business Name): WAYNE MEMORIAL COMMUNITY HEALTH CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2015
Last Update Date: 10/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1839 FAIR AVE
HONESDALE PA
18431-2121
US

IV. Provider business mailing address

601 PARK ST
HONESDALE PA
18431-1445
US

V. Phone/Fax

Practice location:
  • Phone: 570-251-6500
  • Fax:
Mailing address:
  • Phone: 570-251-6641
  • Fax: 570-253-8228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: FREDERICK JACKSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 570-253-8450