Basic Information
| Provider Information | |||||||||
| NPI: | 1073813846 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALLEGHENY CLINIC | ||||||||
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| OtherOrganizationName: | SUBURBAN RADIOLOGY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 ALLEGHENY CTR FL 7 | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152125255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4123305861 | ||||||||
| FaxNumber: | 4123305844 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 S JACKSON AVE | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152023428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4127346015 | ||||||||
| FaxNumber: | 4127316830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2010 | ||||||||
| LastUpdateDate: | 11/06/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NOEL | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 4123305861 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0206X | 04235-02 | PA | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1007317140382 | 05 | PA | MEDICAID |