Provider Demographics
NPI:1992992796
Name:NORTHEASTERN PENNSYLVANIA PLASTIC SURGERY ASSOCIATES LTD
Entity type:Organization
Organization Name:NORTHEASTERN PENNSYLVANIA PLASTIC SURGERY ASSOCIATES LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:W
Authorized Official - Last Name:BLOMAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-347-1712
Mailing Address - Street 1:1222 MARION ST
Mailing Address - Street 2:
Mailing Address - City:DUNMORE
Mailing Address - State:PA
Mailing Address - Zip Code:18509-2458
Mailing Address - Country:US
Mailing Address - Phone:570-347-1712
Mailing Address - Fax:570-963-0534
Practice Address - Street 1:1222 MARION ST
Practice Address - Street 2:
Practice Address - City:DUNMORE
Practice Address - State:PA
Practice Address - Zip Code:18509-2458
Practice Address - Country:US
Practice Address - Phone:570-347-1712
Practice Address - Fax:570-963-0534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD017502E208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAE63285Medicare UPIN
PA031415Medicare PIN