Healthcare Provider Details

I. General information

NPI: 1366725418
Provider Name (Legal Business Name): SCRANTON CARDIOVASCULAR PHYSICIAN SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2011
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

743 JEFFERSON AVE STE 305
SCRANTON PA
18510-1639
US

IV. Provider business mailing address

4000 MERIDIAN BLVD
FRANKLIN TN
37067-6325
US

V. Phone/Fax

Practice location:
  • Phone: 570-342-1776
  • Fax: 570-207-1910
Mailing address:
  • Phone: 615-465-7000
  • Fax: 615-628-6877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER L JACKSON
Title or Position: SENIOR DIRECTOR PROVIDER ENROLLMENT
Credential:
Phone: 877-892-9815