Healthcare Provider Details

I. General information

NPI: 1831201276
Provider Name (Legal Business Name): PEDIATRIC ASSOCIATES OF KINGSTON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 3RD AVE STE 1
KINGSTON PA
18704-5802
US

IV. Provider business mailing address

451 3RD AVE
KINGSTON PA
18704-5802
US

V. Phone/Fax

Practice location:
  • Phone: 570-288-6543
  • Fax: 570-288-7130
Mailing address:
  • Phone: 570-288-6543
  • Fax: 570-288-7130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics 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: JR VOUGHT
Title or Position: PRACTICE MANAGER
Credential:
Phone: 570-288-6543