Healthcare Provider Details

I. General information

NPI: 1528345931
Provider Name (Legal Business Name): SCRANTON QUINCY CLINIC COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2011
Last Update Date: 03/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

748 QUINCY AVE SUITE 1A
SCRANTON PA
18510-1739
US

IV. Provider business mailing address

PO BOX 689022
FRANKLIN TN
37068-9022
US

V. Phone/Fax

Practice location:
  • Phone: 570-342-5253
  • Fax: 570-342-6038
Mailing address:
  • Phone: 877-309-5312
  • Fax: 615-465-2877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier102669377-0003
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

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