Healthcare Provider Details
I. General information
NPI: 1235171646
Provider Name (Legal Business Name): MARK CRUCIANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y
II. Dates (important events)
Enumeration Date: 06/11/2006
Last Update Date: 04/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:
III. Provider practice location address
1418 WYOMING AVE
SCRANTON PA
18509
US
IV. Provider business mailing address
1418 WYOMING AVE
SCRANTON PA
18509
US
V. Phone/Fax
- Phone: 570-341-9730
- Fax: 570-341-9731
- Phone: 570-341-9730
- Fax: 570-341-9731
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 207RR0500X |
| Taxonomy | Rheumatology Physician |
| License Number | MD041260L |
| License Number State | PA |
VII. Legacy identifiers
For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:
| # 1 | |
| Identifier | E55838 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | STERLING |
| # 2 | |
| Identifier | 077077 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | 1ST PRIORITY |
| # 3 | |
| Identifier | 614715 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | FEDERAL BLUE SHIELD |
| # 4 | |
| Identifier | 505461 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | AETNA |
| # 5 | |
| Identifier | 614715 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | PA BLUE SHIELD |
| # 6 | |
| Identifier | 73790 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | MEDPLUS |
| # 7 | |
| Identifier | 614715 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | FIRST PRIORITY LIFE |
| # 8 | |
| Identifier | PC0196 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | CHAMPUS |
| # 9 | |
| Identifier | 2Y8654 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | HLTH NET |
| # 10 | |
| Identifier | 12093 200 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | GEISINGER HEALTH |
| # 11 | |
| Identifier | 18787 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | GEISINGER |
| # 12 | |
| Identifier | 505471 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | AETNA |
VIII. Authorized Official
Name:
Title or Position:
Credential:
Phone:
