Basic Information
Provider Information | |||||||||
NPI: | 1932195492 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SCRANTON TEMPLE RESIDENCY PROGRAM FACULTY SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 185101624 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5709410630 | ||||||||
FaxNumber: | 5709410648 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/21/2005 | ||||||||
LastUpdateDate: | 07/24/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PRIMERO | ||||||||
AuthorizedOfficialFirstName: | ELISORO | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 5709410630 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 001508252 | 05 | PA |   | MEDICAID |