Basic Information
| Provider Information | |||||||||
| NPI: | 1689707549 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEALTH POCONOS, INC. | ||||||||
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| OtherOrganizationName: | RIVERSIDE REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 W MICHIGAN ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532032903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149088119 | ||||||||
| FaxNumber: | 4149087105 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 COMMUNITY DR | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | TOBYHANNA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 184668985 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708399975 | ||||||||
| FaxNumber: | 5708399274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 06/29/2012 | ||||||||
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| AuthorizedOfficialLastName: | MAASSEN | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | COMPLIANCE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4149088119 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0401X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) | 261QR0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 1467795 | 05 | PA | MEDICAID |