1497704787 NPI number — J MICHAEL TEDESCO D.O.

Table of content: J MICHAEL TEDESCO D.O. (NPI 1497704787)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497704787 NPI number — J MICHAEL TEDESCO D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TEDESCO
Provider First Name:
J
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497704787
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
610 WYOMING AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGSTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18704-3702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-288-5441
Provider Business Mailing Address Fax Number:
570-288-5842

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
743 JEFFERSON AVE
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
SCRANTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18510-1635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-341-9818
Provider Business Practice Location Address Fax Number:
570-341-9950
Provider Enumeration Date:
05/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207VX0000X , with the licence number:  OS003900L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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