Organization
LACKAWANNA MEDICAL GROUP PC
Active
Organization
LACKAWANNA MEDICAL GROUP PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. CHARLES THOMAS GRAD JR. (BUSINESS MANAGER)
(570) 348-1130
Entity
Organization
Contact information
Practice address
201 SMALLACOMBE DR, SCRANTON, PA 18508-2616
(570) 961-0171
(570) 207-2411
Mailing address
201 SMALLACOMBE DR, SCRANTON, PA 18508-2616
(570) 961-0171
(570) 207-2411
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
—
—
207R00000X
Internal Medicine Physician
Primary
—
—
207RC0000X
Cardiovascular Disease Physician
—
—
207RG0100X
Gastroenterology Physician
—
—
207UN0901X
Nuclear Cardiology Physician
—
—
208000000X
Pediatrics Physician
—
—
363A00000X
Physician Assistant
—
—
363LF0000X
Family Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000676727
—
PA
Enumeration date
11/30/2006
Last updated
03/03/2016
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