Basic Information
| Provider Information | |||||||||
| NPI: | 1578906483 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHERN TIER GASTROENTEROLOGY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 681 SCRANTON CARBONDALE HWY | ||||||||
| Address2: | |||||||||
| City: | EYNON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 184031022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708765900 | ||||||||
| FaxNumber: | 5708765300 | ||||||||
| Practice Location | |||||||||
| Address1: | 681 SCRANTON CARBONDALE HWY | ||||||||
| Address2: | |||||||||
| City: | EYNON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 184031022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708765900 | ||||||||
| FaxNumber: | 5708765300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2013 | ||||||||
| LastUpdateDate: | 04/10/2013 | ||||||||
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| AuthorizedOfficialLastName: | SHAH | ||||||||
| AuthorizedOfficialFirstName: | NAYAN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDEN T | ||||||||
| AuthorizedOfficialTelephone: | 5708765900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 367500000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.