Healthcare Provider Details

I. General information

NPI: 1033441092
Provider Name (Legal Business Name): PEDIATRIC PRACTICES OF NORTHEASTERN PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2010
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 INDUSTRIAL PARK RD
LAKE ARIEL PA
18436-5606
US

IV. Provider business mailing address

1837 FAIR AVE
HONESDALE PA
18431-2121
US

V. Phone/Fax

Practice location:
  • Phone: 570-689-7565
  • Fax: 570-689-4803
Mailing address:
  • Phone: 570-689-7565
  • Fax: 570-689-4803

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

VII. Legacy identifiers

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

# 1
Identifier1007422260016
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier39-3888
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerCMS CERTIFICATION NUMBER

VIII. Authorized Official

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