Healthcare Provider Details

I. General information

NPI: 1962495374
Provider Name (Legal Business Name): CHARLES N. BARAX MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 07/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 N WEBSTER AVE
SCRANTON PA
18510-1808
US

IV. Provider business mailing address

613 N WEBSTER AVE
SCRANTON PA
18510-1808
US

V. Phone/Fax

Practice location:
  • Phone: 570-348-0394
  • Fax: 570-348-0398
Mailing address:
  • Phone: 570-348-0394
  • Fax: 570-348-0398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD072674L
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier0018273800012
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: