Basic Information
Provider Information | |||||||||
NPI: | 1003996778 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SAINT VINCENT MEDICAL EDUCATION AND RESEARCH INSTITUTE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SAINT VINCENT MEDICAL GROUP SPECIALISTS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3530 PEACH ST | ||||||||
Address2: | SUITE LL1 | ||||||||
City: | ERIE | ||||||||
State: | PA | ||||||||
PostalCode: | 165082768 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8148605036 | ||||||||
FaxNumber: | 8148605063 | ||||||||
Practice Location | |||||||||
Address1: | 232 W 25TH ST | ||||||||
Address2: |   | ||||||||
City: | ERIE | ||||||||
State: | PA | ||||||||
PostalCode: | 165440002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8144525000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/17/2006 | ||||||||
LastUpdateDate: | 11/02/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BALLMAN | ||||||||
AuthorizedOfficialFirstName: | PATRICIA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 8144525296 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology |   | 207N00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |   | 207QS0010X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207R00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RG0300X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207RH0002X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine | 208VP0000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 2080P0202X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 208200000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |   | 207RC0000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 2084V0102X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Vascular Neurology | 207V00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
No ID Information.