Basic Information
| Provider Information | |||||||||
| NPI: | 1003219411 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALLEGHENY HEALTH NETWORK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4815 LIBERTY AVE | ||||||||
| Address2: | SUITE M56 | ||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152242156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4125785539 | ||||||||
| FaxNumber: | 4126056320 | ||||||||
| Practice Location | |||||||||
| Address1: | 4815 LIBERTY AVE | ||||||||
| Address2: | SUITE M56 | ||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152242156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4125785539 | ||||||||
| FaxNumber: | 4126056320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2014 | ||||||||
| LastUpdateDate: | 09/29/2014 | ||||||||
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| AuthorizedOfficialLastName: | AJINE-BASIL | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN ASSISTANT/SURGERY | ||||||||
| AuthorizedOfficialTelephone: | 5868080907 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | PA-C | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208C00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | MA057154 | 01 | PA | COMMONWEALTH OF PENNSYLVANIA | OTHER |