Provider Demographics
NPI:1548487218
Name:BACK MOUNTAIN NEURODIAGNOSTICS, PC
Entity type:Organization
Organization Name:BACK MOUNTAIN NEURODIAGNOSTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:EVAN
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-696-4348
Mailing Address - Street 1:165 S MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:TRUCKSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18708-1418
Mailing Address - Country:US
Mailing Address - Phone:570-696-4348
Mailing Address - Fax:
Practice Address - Street 1:165 S MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:TRUCKSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18708-1418
Practice Address - Country:US
Practice Address - Phone:570-696-4348
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC009260111NN0400X
PADC007819L111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABA1689016OtherGROUPBCBS
PAV00821Medicare UPIN
PABA1689016OtherGROUPBCBS