=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790009488
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHEAST PHYSICIAN HOUSECALLS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2010
-----------------------------------------------------
Last Update Date | 03/24/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 52 DUNDAFF ST
-----------------------------------------------------
City | CARBONDALE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18407-1879
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-650-7282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 WOODLANDS EDGE DR
-----------------------------------------------------
City | OLYPHANT
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18447-9793
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-650-7282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KURT P MORAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 570-840-7056
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------