=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053668798
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POCONO ADVANCED MEDICAL CLINIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2012
-----------------------------------------------------
Last Update Date | 08/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 144 E BROWN ST
-----------------------------------------------------
City | EAST STROUDSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18301-2922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-424-1105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 144 E BROWN ST
-----------------------------------------------------
City | EAST STROUDSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18301-2922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MIHAELA F HANGAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 570-424-1105
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MD444904
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MD444372
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------