Basic Information
| Provider Information | |||||||||
| NPI: | 1073883161 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY LIFE CENTER CORP | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | PITTSBURGH MERCY FAMILY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 REEDSDALE ST | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152332109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4126970712 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 249 SOUTH 9TH STREET | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 15203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4126973260 | ||||||||
| FaxNumber: | 4126973263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2012 | ||||||||
| LastUpdateDate: | 10/12/2012 | ||||||||
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| AuthorizedOfficialLastName: | ANGLUM | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PATIENT ACCOUNTING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4126970712 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 165912 | 01 | PA | MEDICARE | OTHER | 1604175 | 01 | PA | GATEWAY HEALTH PLANS | OTHER | 2684111 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER |