Basic Information
| Provider Information | |||||||||
| NPI: | 1104292960 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GEISINGER WYOMING VALLEY MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | GEISINGER PITTSTON RADIOLOGY, A SERVICE OF GWV | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 NORTH ACADEMY AVENUE | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178224903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702715555 | ||||||||
| FaxNumber: | 5702716578 | ||||||||
| Practice Location | |||||||||
| Address1: | 42 NORTH MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PITTSTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706540880 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2015 | ||||||||
| LastUpdateDate: | 10/02/2015 | ||||||||
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| AuthorizedOfficialLastName: | MULL | ||||||||
| AuthorizedOfficialFirstName: | CINDY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR CREDENTIALING/ENROLLMENTS | ||||||||
| AuthorizedOfficialTelephone: | 5702716603 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.