=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720040090
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH COLUMBIA MEDICAL OFFICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4469 RED ROCK RD
-----------------------------------------------------
City | BENTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17814-7606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-925-6424
-----------------------------------------------------
Fax | 570-925-5930
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 390
-----------------------------------------------------
City | BENTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17814-0390
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-925-6424
-----------------------------------------------------
Fax | 570-925-5930
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RICHARD A PRISUTA
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 570-925-6424
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------