Basic Information
| Provider Information | |||||||||
| NPI: | 1164439006 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SCRANTON TEMPLE RESIDENCY PROGRAM FACULTY SERVICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 746 JEFFERSON AVENUE | ||||||||
| Address2: | |||||||||
| City: | SCRANTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703432383 | ||||||||
| FaxNumber: | 5709636133 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 S. WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | JERMYN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703839934 | ||||||||
| FaxNumber: | 5703836258 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 07/24/2008 | ||||||||
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| AuthorizedOfficialLastName: | PRIMPRO | ||||||||
| AuthorizedOfficialFirstName: | ELIDORU | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5709410630 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | SP007899 | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.