=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790961274
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUZERNE COUNTY GENERAL PRACTICE ASSOCIATES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2008
-----------------------------------------------------
Last Update Date | 05/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1701 WYOMING AVE
-----------------------------------------------------
City | EXETER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18643-1491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-655-2959
-----------------------------------------------------
Fax | 570-655-9213
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1701 WYOMING AVE
-----------------------------------------------------
City | EXETER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18643-1491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-655-2959
-----------------------------------------------------
Fax | 570-655-9213
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MBR
-----------------------------------------------------
Name | ANDREW J STUKA
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 570-655-2959
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | OS003170L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------