Basic Information
| Provider Information | |||||||||
| NPI: | 1649748005 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE WRIGHT CENTER MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE WRIGHT CENTER MEDICAL GROUP DIABETES EDUCATION | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 S WASHINGTON AVE STE 1000 | ||||||||
| Address2: | |||||||||
| City: | SCRANTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 185053814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703432383 | ||||||||
| FaxNumber: | 5703433923 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 S WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | JERMYN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 184331121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702300019 | ||||||||
| FaxNumber: | 5702300013 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2018 | ||||||||
| LastUpdateDate: | 10/07/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DANIELS | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5703432383 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE WRIGHT CENTER MEDICAL GROUP | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174H00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Health Educator |
ID Information
| ID | Type | State | Issuer | Description | 001508252 | 05 | PA | MEDICAID |