Provider Demographics
NPI:1114939451
Name:ORTHOPAEDIC CONSULTANTS OF WYOMING VALLEY LLC
Entity type:Organization
Organization Name:ORTHOPAEDIC CONSULTANTS OF WYOMING VALLEY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:RAKLEWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-288-3535
Mailing Address - Street 1:PO BOX 1463
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-0463
Mailing Address - Country:US
Mailing Address - Phone:570-288-3535
Mailing Address - Fax:570-288-0804
Practice Address - Street 1:390 PIERCE ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5532
Practice Address - Country:US
Practice Address - Phone:570-288-3535
Practice Address - Fax:570-288-0804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018536010001Medicaid
PA925341OtherBLUE SHIELD
PA0018536010001Medicaid