Healthcare Provider Details

I. General information

NPI: 1578043592
Provider Name (Legal Business Name): MGF ENTERPRISES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2018
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 KENNEDY BLVD STE 2
PITTSTON PA
18640-1814
US

IV. Provider business mailing address

250 KENNEDY BLVD STE 2
PITTSTON PA
18640-1814
US

V. Phone/Fax

Practice location:
  • Phone: 570-760-1901
  • Fax:
Mailing address:
  • Phone: 570-760-1901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberOS008694L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL CAMPENNI
Title or Position: PRESIDENT
Credential: DO
Phone: 570-760-1901