Provider Demographics
NPI:1871781518
Name:WAYNE SURGICAL ASSOCIATES PC
Entity type:Organization
Organization Name:WAYNE SURGICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:W
Authorized Official - Last Name:TIETJEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-253-2620
Mailing Address - Street 1:507 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-1733
Mailing Address - Country:US
Mailing Address - Phone:570-253-2620
Mailing Address - Fax:570-253-2651
Practice Address - Street 1:507 HIGH ST
Practice Address - Street 2:
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431-1733
Practice Address - Country:US
Practice Address - Phone:570-253-2620
Practice Address - Fax:570-253-2651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD016938E208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
T1153927Medicare PIN
PAB40074Medicare UPIN