Healthcare Provider Details

I. General information

NPI: 1235332263
Provider Name (Legal Business Name): JILL KISSOLOVEGE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 02/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1141 MOOSIC ST STE 3
SCRANTON PA
18505-2105
US

IV. Provider business mailing address

1141 MOOSIC ST STE 3
SCRANTON PA
18505-2105
US

V. Phone/Fax

Practice location:
  • Phone: 570-800-5926
  • Fax:
Mailing address:
  • Phone: 570-800-5926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS-010470-L
License Number StatePA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: