Provider Demographics
NPI:1144280504
Name:SYMULESKI, JOSEPH ALEX (MPT)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:ALEX
Last Name:SYMULESKI
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:EYNON
Mailing Address - State:PA
Mailing Address - Zip Code:18403-1476
Mailing Address - Country:US
Mailing Address - Phone:570-876-3339
Mailing Address - Fax:570-307-1771
Practice Address - Street 1:334 MAIN ST
Practice Address - Street 2:
Practice Address - City:DICKSON CITY
Practice Address - State:PA
Practice Address - Zip Code:18519-1620
Practice Address - Country:US
Practice Address - Phone:570-307-1769
Practice Address - Fax:570-307-1771
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT012819-L174400000X
PADAPT000435174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA820074OtherBLUE CROSS PIN
PA100588MYQMedicare PIN