Provider Demographics
NPI:1215125133
Name:POCONO NEUROLOGY ASSOCIATES
Entity type:Organization
Organization Name:POCONO NEUROLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GIRIWARLAL
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-421-1213
Mailing Address - Street 1:144 E BROWN ST
Mailing Address - Street 2:
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-2922
Mailing Address - Country:US
Mailing Address - Phone:570-421-1213
Mailing Address - Fax:570-421-4541
Practice Address - Street 1:144 E BROWN ST
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-2922
Practice Address - Country:US
Practice Address - Phone:570-421-1213
Practice Address - Fax:570-421-4541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD016750E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011360030001Medicaid
PA404872Medicare PIN