Provider Demographics
NPI:1316124902
Name:NE PEDIATRICS, INC
Entity type:Organization
Organization Name:NE PEDIATRICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-347-5605
Mailing Address - Street 1:440 N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18504-1720
Mailing Address - Country:US
Mailing Address - Phone:570-347-5605
Mailing Address - Fax:570-489-4583
Practice Address - Street 1:440 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18504-1720
Practice Address - Country:US
Practice Address - Phone:570-347-5605
Practice Address - Fax:570-489-4583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-25
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD063076L208000000X
PAMD009571E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA361842OtherBLUE SHIELD
PA1007577660001Medicaid