Healthcare Provider Details

I. General information

NPI: 1780820068
Provider Name (Legal Business Name): WAYNE MEMORIAL COMMUNITY HEALTH CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2008
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

543 EASTON TPKE SUITE 105
LAKE ARIEL PA
18436-4798
US

IV. Provider business mailing address

601 PARK ST
HONESDALE PA
18431-1445
US

V. Phone/Fax

Practice location:
  • Phone: 570-689-9965
  • Fax: 570-689-0387
Mailing address:
  • Phone: 570-689-9965
  • Fax: 570-689-0387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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