Provider Demographics
NPI:1194803825
Name:MT. POCONO FAMILY PRACTICE CENTER
Entity type:Organization
Organization Name:MT. POCONO FAMILY PRACTICE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:PTAKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-646-6905
Mailing Address - Street 1:RT 940
Mailing Address - Street 2:PO BOX 147
Mailing Address - City:POCONO LAKE
Mailing Address - State:PA
Mailing Address - Zip Code:18347
Mailing Address - Country:US
Mailing Address - Phone:570-646-6905
Mailing Address - Fax:570-646-6009
Practice Address - Street 1:RT 940
Practice Address - Street 2:147
Practice Address - City:POCONO LAKE
Practice Address - State:PA
Practice Address - Zip Code:18347
Practice Address - Country:US
Practice Address - Phone:570-646-6905
Practice Address - Fax:570-646-6009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD040378L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E59330Medicare UPIN
PA187471Medicare ID - Type Unspecified