=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497717482
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SURGICAL SPECIALISTS OF WYOMING VALLEY, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2006
-----------------------------------------------------
Last Update Date | 08/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 S RIVER ST
-----------------------------------------------------
City | PLAINS
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18705-1143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-821-1100
-----------------------------------------------------
Fax | 570-821-1108
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 S RIVER ST
-----------------------------------------------------
City | PLAINS
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18705-1143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-821-1100
-----------------------------------------------------
Fax | 570-821-1108
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | DR. MARIE ROKE THOMAS
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 570-821-1100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------