Basic Information
| Provider Information | |||||||||
| NPI: | 1700832151 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | POCONO EMERGENCY PHYSICIANS, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 RIVER RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CONSHOHOCKEN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194282439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108342828 | ||||||||
| FaxNumber: | 6108242862 | ||||||||
| Practice Location | |||||||||
| Address1: | 206 E BROWN ST | ||||||||
| Address2: | |||||||||
| City: | EAST STROUDSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 183013006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704763353 | ||||||||
| FaxNumber: | 5704216801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 08/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | FAVINI | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5704763625 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N/A | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0017968370002 | 05 | PA | MEDICAID | PO572711 | 01 | PA | BLUE SHIELD | OTHER |