Healthcare Provider Details

I. General information

NPI: 1548223399
Provider Name (Legal Business Name): CYRIL PUHALLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 ADAMS AVE
SCRANTON PA
18503-1604
US

IV. Provider business mailing address

326 ADAMS AVE
SCRANTON PA
18503-1604
US

V. Phone/Fax

Practice location:
  • Phone: 570-348-6100
  • Fax: 570-969-8626
Mailing address:
  • Phone: 570-348-6100
  • Fax: 570-969-8626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD015383E
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier0005566850004
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: