Healthcare Provider Details

I. General information

NPI: 1205004207
Provider Name (Legal Business Name): PAUL A. TOMCYKOSKI DO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2008
Last Update Date: 02/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 ROBERT MELLOW DR
JESSUP PA
18434
US

IV. Provider business mailing address

1355 ROBERT MELLOW DR
JESSUP PA
18434
US

V. Phone/Fax

Practice location:
  • Phone: 570-383-5453
  • Fax: 570-489-4583
Mailing address:
  • Phone: 570-383-5453
  • Fax: 570-489-4583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS009027L
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier0017888900002
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: PAUL A TOMCYKOSKI
Title or Position: PHYSICIAN
Credential: DO
Phone: 570-383-5453