Healthcare Provider Details

I. General information

NPI: 1396075891
Provider Name (Legal Business Name): MATERNAL & FAMILY HEALTH SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2010
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 MADISON AVE
SCRANTON PA
18510-1631
US

IV. Provider business mailing address

15 PUBLIC SQ SUITE 600
WILKES BARRE PA
18701-1702
US

V. Phone/Fax

Practice location:
  • Phone: 570-961-5550
  • Fax: 570-961-3844
Mailing address:
  • Phone: 570-826-1777
  • Fax: 570-823-3040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD065507L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD065507L
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier1007678420045
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier1030047770005
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 3
Identifier0017358870011
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 4
Identifier1029682400005
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: LAURIE GERMINO
Title or Position: VICE PRESIDENT OF FINANCE & PLANNIN
Credential:
Phone: 570-826-1777