Healthcare Provider Details

I. General information

NPI: 1942350087
Provider Name (Legal Business Name): SAMIR B PANCHOLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

286 MAIN ST
OLYPHANT PA
18447-2317
US

IV. Provider business mailing address

286 MAIN ST
OLYPHANT PA
18447-2317
US

V. Phone/Fax

Practice location:
  • Phone: 570-876-6140
  • Fax:
Mailing address:
  • Phone: 570-876-6140
  • Fax: 570-872-7776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD045919L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberMD045919L
License Number StatePA

VIII. Authorized Official

Name: SAMIR B PANCHOLY
Title or Position: OWNER
Credential: MD
Phone: 570-876-6140