Basic Information
| Provider Information | |||||||||
| NPI: | 1114939451 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPAEDIC CONSULTANTS OF WYOMING VALLEY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1463 | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187040463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702883535 | ||||||||
| FaxNumber: | 5702880804 | ||||||||
| Practice Location | |||||||||
| Address1: | 390 PIERCE ST | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187045532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702883535 | ||||||||
| FaxNumber: | 5702880804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | RAKLEWICZ | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 5702883535 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0018536010001 | 05 | PA | MEDICAID | 925341 | 01 | PA | BLUE SHIELD | OTHER |