Basic Information
| Provider Information | |||||||||
| NPI: | 1023243391 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIMEMED, P.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VIEWMONT MEDICAL LABS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5 MORGAN HWY | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | SCRANTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 185082641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705587414 | ||||||||
| FaxNumber: | 5702074287 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 ABINGTON EXECUTIVE PARK | ||||||||
| Address2: | SUITE C | ||||||||
| City: | CLARKS SUMMIT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 184112258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702073333 | ||||||||
| FaxNumber: | 5707028131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2009 | ||||||||
| LastUpdateDate: | 08/25/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SIDLOSKI | ||||||||
| AuthorizedOfficialFirstName: | MYRON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF ADMINISTRATIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5705587412 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRIMEMED, P.C. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CAO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 030946 | PA | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 2097690 | 01 | PA | BLUE SHIELD | OTHER | 100750818 | 05 | PA | MEDICAID |