Healthcare Provider Details

I. General information

NPI: 1831170869
Provider Name (Legal Business Name): JAMSHID KHADEMI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 MULBERRY ST.
SCRANTON PA
18510-6800
US

IV. Provider business mailing address

100 N ACADEMY AVE
DANVILLE PA
17822-4903
US

V. Phone/Fax

Practice location:
  • Phone: 570-703-8259
  • Fax: 570-703-7250
Mailing address:
  • Phone: 570-271-6144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD064062L
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier01716353
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier050083939
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerRR MEDICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: