Basic Information
| Provider Information | |||||||||
| NPI: | 1205854650 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | POCONO MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | POCONO GENERAL SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 206 E BROWN ST | ||||||||
| Address2: | POCONO HEALTHCARE MGMT. - PROFESSIONAL BLDG. | ||||||||
| City: | E STROUDSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 183013006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704204969 | ||||||||
| FaxNumber: | 5704763754 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 PLAZA CT | ||||||||
| Address2: | SUITE D | ||||||||
| City: | E STROUDSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 183018262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704262301 | ||||||||
| FaxNumber: | 5704262306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WALSH | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, CFO | ||||||||
| AuthorizedOfficialTelephone: | 5704214000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.