Basic Information
Provider Information | |||||||||
NPI: | 1003897307 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PENN NORTH CENTERS FOR ADVANCED WOUND CARE PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 232 W 25TH ST | ||||||||
Address2: |   | ||||||||
City: | ERIE | ||||||||
State: | PA | ||||||||
PostalCode: | 165440002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8144527878 | ||||||||
FaxNumber: | 8144527883 | ||||||||
Practice Location | |||||||||
Address1: | 232 W 25TH ST | ||||||||
Address2: |   | ||||||||
City: | ERIE | ||||||||
State: | PA | ||||||||
PostalCode: | 165440002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8144527878 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/14/2005 | ||||||||
LastUpdateDate: | 09/11/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SERENA | ||||||||
AuthorizedOfficialFirstName: | THOMAS | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8144527878 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 207Q00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 2083P0011X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Undersea and Hyperbaric Medicine | 208600000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 100964725 | 05 | PA |   | MEDICAID | DC2954 | 01 |   | RAILROAD MEDICARE | OTHER |