Provider Demographics
NPI:1245311067
Name:POCONO SURGICAL ASSOCIATES
Entity type:Organization
Organization Name:POCONO SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-421-5997
Mailing Address - Street 1:391 E BROWN ST
Mailing Address - Street 2:
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-9101
Mailing Address - Country:US
Mailing Address - Phone:570-421-5997
Mailing Address - Fax:570-421-7635
Practice Address - Street 1:391 E BROWN ST
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-9101
Practice Address - Country:US
Practice Address - Phone:570-421-5997
Practice Address - Fax:570-421-7635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD028193E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011526240007Medicaid
PA118962Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID
PA0011526240007Medicaid
PA4176220001Medicare NSC