MEDICARE: BACK MOUNTAIN ORTHOPEDICS P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207XS0106X	Orthopaedic Hand Surgery Physician	MD024634E	PA

General Provider Information

NPI Number	:	1073063079
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACK MOUNTAIN ORTHOPEDICS P.C.

Provider Business Mailing Address
First Line	:	2800 MEMORIAL HWY
Second Line	:	SUITE 1
City	:	DALLAS
State	:	PA
Zip	:	18612-1569
Country	:	US
Telephone Number	:	570-675-6737
Fax Number	:	570-675-7882

Provider Business Practice Location Address
First Line	:	2800 MEMORIAL HWY
Second Line	:	SUITE 1
City	:	DALLAS
State	:	PA
Zip	:	18612-1569
Country	:	US
Telephone Number	:	570-675-6737
Fax Number	:	570-675-7882

Authorized Official
Title or Position	:	OWNER
Name	:	DR. THOMAS WILLIAM BYRON
Credential	:	M.D.
Telephone Number	:	570-675-6737

Provider Enumeration Date	:	10/13/2016
Last Update Date	:	10/13/2016

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