Healthcare Provider Details

I. General information

NPI: 1922275320
Provider Name (Legal Business Name): PHYSICIANS HEALTH ALLIANCE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 11/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

748 QUINCY AVE SUITE 2A
SCRANTON PA
18510-1739
US

IV. Provider business mailing address

1401 ELECTRIC ST
DUNMORE PA
18509-2098
US

V. Phone/Fax

Practice location:
  • Phone: 570-961-0851
  • Fax: 570-344-4285
Mailing address:
  • Phone: 570-969-9005
  • Fax: 570-207-0706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier763807
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerBLUE SHIELD
# 2
Identifier1007712910036
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: PATRICIA KANE
Title or Position: COO
Credential:
Phone: 570-969-9005