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General NPI Number Information
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NPI Number | 1689187072
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Entity Type | Organization
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Legal Business Name | NORTHEAST KNEE AND JOINT INSTITUTE, LLC.
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Dates
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Enumeration Date | 11/08/2017
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Last Update Date | 07/15/2019
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Provider Practice Location Address
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Address Line | 3832 YALICK PLAZA ROUTE 415 UNIT 7
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City | DALLAS
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State | PA
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Zip | 18612-7753
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Country | US
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Telephone | 570-213-5221
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Fax | 570-227-3316
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Provider Business Mailing Address
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Address Line | PO BOX 3367
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City | WILLIAMSPORT
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State | PA
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Zip | 17701-0367
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Country | US
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Telephone | 570-213-5221
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Fax | 570-227-3316
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Authorized Official
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Title or Position | OWNER
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Name | EDWIN ROMAN
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Credential | MD
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Telephone | 570-213-5221
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number |
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License Number State |
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