NPIMap

Organization Active NPI

Lackawanna Medical Group PC

  • Internal Medicine Physician
  • Scranton, PA
National Provider Identifier
1770650962
Registry record updated Mar 3, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
LACKAWANNA MEDICAL GROUP PC
Practice address
201 Smallacombe Dr
Scranton, PA 18508-2616
Phone
(570) 961-0171
Fax
(570) 207-2411
NPI assigned
Nov 30, 2006
Last updated
Mar 3, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 3, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Charles Thomas Grad Jr.NPI 1093723322
Title
Business Manager
Phone
(570) 348-1130

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 8

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X NU
Family Nurse Practitioner 363LF0000X NU
Family Medicine Physician 207Q00000X NU
Internal Medicine Physician 207R00000X NU Primary
Cardiovascular Disease Physician 207RC0000X NU
Gastroenterology Physician 207RG0100X NU
Nuclear Cardiology Physician 207UN0901X NU
Pediatrics Physician 208000000X NU

Addresses

Primary practice location

201 Smallacombe Dr
Scranton, PA 18508-2616

Mailing address

201 Smallacombe Dr
Scranton, PA 18508-2616
Phone (570) 961-0171

Other identifiers 1

IdentifierTypeStateIssuer
000676727MedicaidPA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040616001211 PA Part B Supplier - Clinic/Group Practice 6800870882 Receives reassigned benefits from 6 practitioners
Practice locations: Scranton, PA

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
39D0927570Lackawanna Medical Group PC201 Smallacombe Drive Suite 100, Scranton, PA 18508Certificate of waiverApr 22, 2027

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1164844800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1456963200000",
    "number": "1770650962",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "201 SMALLACOMBE DR",
            "city": "SCRANTON",
            "state": "PA",
            "postal_code": "185082616",
            "telephone_number": "570-961-0171",
            "fax_number": "570-207-2411"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "201 SMALLACOMBE DR",
            "city": "SCRANTON",
            "state": "PA",
            "postal_code": "185082616",
            "telephone_number": "570-961-0171",
            "fax_number": "570-207-2411"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LACKAWANNA MEDICAL GROUP PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-30",
        "last_updated": "2016-03-03",
        "status": "A",
        "authorized_official_last_name": "GRAD",
        "authorized_official_first_name": "CHARLES",
        "authorized_official_middle_name": "THOMAS",
        "authorized_official_title_or_position": "BUSINESS MANAGER",
        "authorized_official_telephone_number": "570-348-1130",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "207RC0000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Cardiovascular Disease",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207RG0100X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Gastroenterology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207UN0901X",
            "taxonomy_group": "",
            "desc": "Nuclear Medicine, Nuclear Cardiology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000676727",
            "state": "PA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Scranton, PA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 3, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.