Basic Information
| Provider Information | |||||||||
| NPI: | 1033258694 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GLADE RUN MEDICAL ASSOCIATES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ADULT MEDICINE ASSOCIATES-KITANNING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9276 SCRANTON RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921217701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586252990 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 300 MEDICAL ARTS BLDG | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | KITTANNING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 162017129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7245451288 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2007 | ||||||||
| LastUpdateDate: | 05/03/2017 | ||||||||
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| AuthorizedOfficialLastName: | PETERSON | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8586252990 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEDVANTX, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | OS016078 | PA | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.