Healthcare Provider Details

I. General information

NPI: 1780219840
Provider Name (Legal Business Name): NANTICOKE MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2020
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 W WASHINGTON ST
NANTICOKE PA
18634-3113
US

IV. Provider business mailing address

PO BOX 3945
NEW HYDE PARK NY
11040-8945
US

V. Phone/Fax

Practice location:
  • Phone: 718-534-7888
  • Fax: 718-874-0088
Mailing address:
  • Phone: 917-774-1787
  • Fax: 718-874-0088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: SHAHID RASUL
Title or Position: CEO
Credential: MD
Phone: 917-774-1787