Basic Information
| Provider Information | |||||||||
| NPI: | 1770592370 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ISL, LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1172 WEST MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | STROUDSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704246187 | ||||||||
| FaxNumber: | 5704246271 | ||||||||
| Practice Location | |||||||||
| Address1: | 1172 WEST MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | STROUDSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704246187 | ||||||||
| FaxNumber: | 5704246271 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 09/29/2015 | ||||||||
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| AuthorizedOfficialLastName: | LEVINSON | ||||||||
| AuthorizedOfficialFirstName: | ILAN | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5704246187 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 0016136970009 | 05 | PA | MEDICAID | 0000479187 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER |