Healthcare Provider Details

I. General information

NPI: 1912206723
Provider Name (Legal Business Name): SCRANTON CLINIC COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2011
Last Update Date: 08/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

746 JEFFERSON AVE 3RD FLOOR
SCRANTON PA
18510-1624
US

IV. Provider business mailing address

4000 MERIDIAN BLVD
FRANKLIN TN
37067-6325
US

V. Phone/Fax

Practice location:
  • Phone: 570-344-9457
  • Fax: 570-343-3731
Mailing address:
  • Phone: 877-892-9813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily 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
Identifier102578488 0001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: DEBBIE T BREWER
Title or Position: DIRECTOR
Credential:
Phone: 877-892-9813