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General NPI Number Information
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NPI Number | 1063621233
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Entity Type | Organization
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Legal Business Name | BACK MOUNTAIN PEDIATRICS
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Dates
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Enumeration Date | 05/22/2007
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 550 MEMORIAL HIGHWAY
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City | DALLAS
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State | PA
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Zip | 18612
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Country | US
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Telephone | 570-675-7955
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Fax | 570-675-7882
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Provider Business Mailing Address
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Address Line | 550 MEMORIAL HIGHWAY SUITE 1
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City | DALLAS
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State | PA
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Zip | 18612
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Country | US
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Telephone | 570-675-7955
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Fax | 570-675-7882
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOAN E GREULICK
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Credential | MD
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Telephone | 570-675-7955
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 022874
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | MD024845E
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License Number State | PA
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