Provider Demographics
NPI:1104974328
Name:NEALE, GARY PAUL (MB CHB)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:PAUL
Last Name:NEALE
Suffix:
Gender:M
Credentials:MB CHB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S RIVER ST
Mailing Address - Street 2:
Mailing Address - City:PLAINS
Mailing Address - State:PA
Mailing Address - Zip Code:18705-1143
Mailing Address - Country:US
Mailing Address - Phone:570-821-1100
Mailing Address - Fax:570-821-1108
Practice Address - Street 1:200 S RIVER ST
Practice Address - Street 2:
Practice Address - City:PLAINS
Practice Address - State:PA
Practice Address - Zip Code:18705-1143
Practice Address - Country:US
Practice Address - Phone:570-821-1100
Practice Address - Fax:570-821-1108
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA95263174400000X
PAMD427857208600000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
196200HUYOtherMEDICARE
PA1025213870001Medicaid