MEDICARE: JOHN S ZAVACKI, M.D.,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	207N00000X	Dermatology Physician	MD009136-E	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZA1635348	OTHER	PA	HIGHMARK BLUE SHIELD

General Provider Information

NPI Number	:	1770770497
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN S ZAVACKI, M.D.,P.C.

Provider Business Mailing Address
First Line	:	216 N RIVER ST
Second Line	:	SUITE 640 COURTHOUSE SQUARE TOWERS
City	:	WILKES BARRE
State	:	PA
Zip	:	18702-2532
Country	:	US
Telephone Number	:	570-829-0031
Fax Number	:	570-829-0158

Provider Business Practice Location Address
First Line	:	216 N RIVER ST
Second Line	:	SUITE 640 COURTHOUSE SQUARE TOWERS
City	:	WILKES BARRE
State	:	PA
Zip	:	18702-2532
Country	:	US
Telephone Number	:	570-829-0031
Fax Number	:	570-829-0158

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOHN S ZAVACKI
Credential	:	M.D.
Telephone Number	:	570-829-0031

Provider Enumeration Date	:	09/26/2007
Last Update Date	:	09/26/2007

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