Healthcare Provider Details

I. General information

NPI: 1790803302
Provider Name (Legal Business Name): MICHAEL A JALOWIEC DO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 10/09/2023
Certification Date: 10/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 S MAIN ST SUITE 4
OLD FORGE PA
18518-1431
US

IV. Provider business mailing address

821 S MAIN ST SUITE 4
OLD FORGE PA
18518-1497
US

V. Phone/Fax

Practice location:
  • Phone: 570-457-2300
  • Fax: 570-457-6627
Mailing address:
  • Phone: 570-457-2300
  • Fax: 570-457-6627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS007959L
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier0015121390005
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: JOHNNA JALOWIEC
Title or Position: OFFICE MANAGER
Credential:
Phone: 570-851-9618