Provider Demographics
NPI:1215924261
Name:NEUROLOGIC SUBSPECIALTIES INC
Entity type:Organization
Organization Name:NEUROLOGIC SUBSPECIALTIES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:LILIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-961-3933
Mailing Address - Street 1:311 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18503-1230
Mailing Address - Country:US
Mailing Address - Phone:570-961-3933
Mailing Address - Fax:
Practice Address - Street 1:311 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18503-1230
Practice Address - Country:US
Practice Address - Phone:570-961-3933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPAMD026664E2084N0400X, 2084N0402X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Single Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical NeurophysiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010340770001Medicaid
PA0015722260001Medicaid
PA0010340770001Medicaid
PAE55459Medicare UPIN