=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104812502
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PRAVEER JAIN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2005
-----------------------------------------------------
Last Update Date | 10/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 PLAZA COURT, SUITE A PMC PHYSICIAN ASSOCIATES CARDIOLOGY
-----------------------------------------------------
City | EAST STROUDSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18301-8262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-424-9970
-----------------------------------------------------
Fax | 570-424-2899
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 206 E. BROWN ST. POCONO HEALTHCARE MANAGEMENT-PROFESSIONAL CENTER
-----------------------------------------------------
City | EAST STROUDSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18301-3006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-420-4951
-----------------------------------------------------
Fax | 570-476-3754
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | MD057391L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RC0001X
-----------------------------------------------------
Taxonomy Name | Clinical Cardiac Electrophysiology Physician
-----------------------------------------------------
License Number | MD057391L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------