Healthcare Provider Details

I. General information

NPI: 1336175595
Provider Name (Legal Business Name): HORIZON MEDICAL CORPORATION PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 N MAIN AVE
SCRANTON PA
18508-1995
US

IV. Provider business mailing address

4 KELLY ST STE 4
ARCHBALD PA
18403-1627
US

V. Phone/Fax

Practice location:
  • Phone: 570-961-9947
  • Fax: 570-341-5043
Mailing address:
  • Phone: 570-876-1735
  • Fax: 570-876-1813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier40158
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerBLUE SHIELD GROUP NUMBER
# 2
Identifier0017929090002
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 3
Identifier809779
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerFIRST PRIORITY HEALTH GRO

VIII. Authorized Official

Name: LISA WRIGHT
Title or Position: CREDENTIALING
Credential:
Phone: 570-876-1735