Basic Information
| Provider Information | |||||||||
| NPI: | 1568407583 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORMANEK | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 827658 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191827658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704204951 | ||||||||
| FaxNumber: | 5704763754 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 E BROWN ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | EAST STROUDSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 183013006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704202188 | ||||||||
| FaxNumber: | 5704213493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 07/22/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 0101232517 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | MD041860L | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | C06778 | 01 | VA | GROUP PTAN | OTHER |