Basic Information
Provider Information | |||||||||
NPI: | 1033172556 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DCA OF CHAMBERSBURG, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | U S RENAL CARE CHAMBERSBURG DIALYSIS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 19119 | ||||||||
Address2: |   | ||||||||
City: | JONESBORO | ||||||||
State: | AR | ||||||||
PostalCode: | 724036601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8709315400 | ||||||||
FaxNumber: | 8709315418 | ||||||||
Practice Location | |||||||||
Address1: | 765 5TH AVE | ||||||||
Address2: | FIFTH AVE PROFESSIONAL CENTER | ||||||||
City: | CHAMBERSBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 172014228 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7172639300 | ||||||||
FaxNumber: | 7172637879 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/07/2006 | ||||||||
LastUpdateDate: | 10/25/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WEINBERG | ||||||||
AuthorizedOfficialFirstName: | THOMAS | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT & SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 2147362700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | U S RENAL CARE INC | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
ID | Type | State | Issuer | Description | 01741721 | 01 | PA | HEALTHMATE | OTHER | 34493 | 01 | PA | HEALTH PARTNERS | OTHER | 1265899 | 01 | PA | GETTYSBURG HEALTH ADMIN | OTHER | 265899 | 01 | PA | MAMSI ALLIANCE | OTHER | 1850 | 01 | PA | PA HIGHMARK | OTHER | 2125722 | 01 | PA | AETNA | OTHER | 1527304 | 01 | PA | GATEWAY MEDICARE ASSURED | OTHER | PPA01555 | 01 | PA | PA CHRONIC RENAL PROGRAM | OTHER | 0017417210001 | 05 | PA |   | MEDICAID | 01741721 | 01 | PA | GATEWAY | OTHER |