Basic Information
| Provider Information | |||||||||
| NPI: | 1982625000 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEVINSON | ||||||||
| FirstName: | ILAN | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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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: | 07/22/2006 | ||||||||
| LastUpdateDate: | 10/15/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | MD055185L | PA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | MD01855L | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 0015426100005 | 05 | PA | MEDICAID | 001542610000S | 05 | PA | MEDICAID | 0000789615 | 01 | PA | HIGHMARK | OTHER |