Healthcare Provider Details

I. General information

NPI: 1700816782
Provider Name (Legal Business Name): PANCOAST & FAGERBURG ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

748 QUINCY AVE SUITE 301B
SCRANTON PA
18510-1739
US

IV. Provider business mailing address

748 QUINCY AVE SUITE 301B
SCRANTON PA
18510-1739
US

V. Phone/Fax

Practice location:
  • Phone: 570-342-5253
  • Fax: 570-342-6038
Mailing address:
  • Phone: 570-342-5253
  • Fax: 570-342-6038

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
Identifier0011414420007
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: RODGER E FAGERBURG
Title or Position: PRESIDENT
Credential: M.D.
Phone: 570-342-5253