Basic Information
| Provider Information | |||||||||
| NPI: | 1073626909 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHARON REGIONAL HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SRHS OUTPATIENT PSYCH CLINIC, GARDEN WAY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 699 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | SHARON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 161462057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249833817 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2375 GARDEN WAY | ||||||||
| Address2: | |||||||||
| City: | HERMITAGE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 161485209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249835454 | ||||||||
| FaxNumber: | 7249835455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SCHAUER | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT FOR FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 7249833815 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 404840 | PA | X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM0850X | 404840 | PA | X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0855X | 404840 | PA | X | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1000000590063 | 05 | PA | MEDICAID | 1000000590068 | 05 | PA | MEDICAID | 1000000590069 | 05 | PA | MEDICAID |