Healthcare Provider Details

I. General information

NPI: 1497704787
Provider Name (Legal Business Name): J MICHAEL TEDESCO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2006
Last Update Date: 03/07/2023
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

743 JEFFERSON AVE SUITE 206
SCRANTON PA
18510-1635
US

IV. Provider business mailing address

610 WYOMING AVE
KINGSTON PA
18704-3702
US

V. Phone/Fax

Practice location:
  • Phone: 570-341-9818
  • Fax: 570-341-9950
Mailing address:
  • Phone: 570-288-5441
  • Fax: 570-288-5842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberOS003900L
License Number StatePA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: