Basic Information
| Provider Information | |||||||||
| NPI: | 1851387013 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STRP FACULTY SERVICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 746 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | SCRANTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 185101624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703432383 | ||||||||
| FaxNumber: | 5709636133 | ||||||||
| Practice Location | |||||||||
| Address1: | 640 MADISON AVE | ||||||||
| Address2: | |||||||||
| City: | SCRANTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 185101607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5709615670 | ||||||||
| FaxNumber: | 5709615991 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | PRIMERO | ||||||||
| AuthorizedOfficialFirstName: | ELIDORO | ||||||||
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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 | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0663952 | 05 | PA | MEDICAID |