Healthcare Provider Details

I. General information

NPI: 1821083700
Provider Name (Legal Business Name): BUCKTAIL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 03/17/2023
Certification Date: 03/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 PINE ST
RENOVO PA
17764-1618
US

IV. Provider business mailing address

1001 PINE ST
RENOVO PA
17764-1618
US

V. Phone/Fax

Practice location:
  • Phone: 570-923-1000
  • Fax: 570-923-1812
Mailing address:
  • Phone: 570-923-1000
  • Fax: 570-923-1812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number549601
License Number StatePA

VIII. Authorized Official

Name: GARY DAILEY JR.
Title or Position: ACCOUNTING / SPECIAL PROJECTS
Credential:
Phone: 570-923-1000