Healthcare Provider Details

I. General information

NPI: 1316124902
Provider Name (Legal Business Name): NE PEDIATRICS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2008
Last Update Date: 01/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 N MAIN AVE
SCRANTON PA
18504-1720
US

IV. Provider business mailing address

440 N MAIN AVE
SCRANTON PA
18504-1720
US

V. Phone/Fax

Practice location:
  • Phone: 570-347-5605
  • Fax: 570-489-4583
Mailing address:
  • Phone: 570-347-5605
  • Fax: 570-489-4583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD063076L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD009571E
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier361842
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerBLUE SHIELD
# 2
Identifier1007577660001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: DR. VINCENT L ROSS
Title or Position: PHYSICIAN
Credential: MD
Phone: 570-347-5605