Provider Demographics
NPI:1023243391
Name:PRIMEMED, P.C.
Entity type:Organization
Organization Name:PRIMEMED, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MYRON
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDLOSKI
Authorized Official - Suffix:
Authorized Official - Credentials:CAO
Authorized Official - Phone:570-558-7412
Mailing Address - Street 1:5 MORGAN HWY
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18508-2641
Mailing Address - Country:US
Mailing Address - Phone:570-558-7414
Mailing Address - Fax:570-207-4287
Practice Address - Street 1:100 ABINGTON EXECUTIVE PARK
Practice Address - Street 2:SUITE C
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411-2258
Practice Address - Country:US
Practice Address - Phone:570-207-3333
Practice Address - Fax:570-702-8131
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIMEMED, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-15
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA030946291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2097690OtherBLUE SHIELD
PA100750818Medicaid
PA2097690OtherBLUE SHIELD