Provider Demographics
NPI:1184177263
Name:CLEANSLATE MEDICAL GROUP OF PENNSYLVANIA LLC
Entity type:Organization
Organization Name:CLEANSLATE MEDICAL GROUP OF PENNSYLVANIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:SMOLAREK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-999-5188
Mailing Address - Street 1:8 CADILLAC DR STE 180
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5393
Mailing Address - Country:US
Mailing Address - Phone:615-425-0220
Mailing Address - Fax:833-279-7074
Practice Address - Street 1:100 N WILKES BARRE BLVD STE 103
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-5240
Practice Address - Country:US
Practice Address - Phone:413-584-2173
Practice Address - Fax:833-279-7074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-26
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty