Healthcare Provider Details

I. General information

NPI: 1447243902
Provider Name (Legal Business Name): WILLIAM R. PREBOLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 03/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 MUNDY ST
WILKES BARRE PA
18702-6830
US

IV. Provider business mailing address

150 MUNDY ST MAC IV BUILDING
WILKES BARRE PA
18702-6830
US

V. Phone/Fax

Practice location:
  • Phone: 570-824-0930
  • Fax: 570-824-7755
Mailing address:
  • Phone: 570-824-0930
  • Fax: 570-824-7755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberMD042746L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD042746L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: