Provider Demographics
NPI:1962405894
Name:WILKES BARRE ASC., LP
Entity type:Organization
Organization Name:WILKES BARRE ASC., LP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AKRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ZALATIMO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-822-9010
Mailing Address - Street 1:545 N RIVER ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-2600
Mailing Address - Country:US
Mailing Address - Phone:570-822-9010
Mailing Address - Fax:570-270-6488
Practice Address - Street 1:545 N RIVER ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-2600
Practice Address - Country:US
Practice Address - Phone:570-822-9010
Practice Address - Fax:570-270-6488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA12831500261Q00000X, 261QA1903X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007426920003Medicaid
PA050342Medicare ID - Type UnspecifiedPROVIDER NUMBER