Basic Information
Provider Information | |||||||||
NPI: | 1093796344 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTERVILLE CLINICS, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1070 OLD NATIONAL PIKE | ||||||||
Address2: |   | ||||||||
City: | FREDERICKTOWN | ||||||||
State: | PA | ||||||||
PostalCode: | 153332114 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7246326801 | ||||||||
FaxNumber: | 7246326312 | ||||||||
Practice Location | |||||||||
Address1: | 1070 OLD NATIONAL PIKE | ||||||||
Address2: |   | ||||||||
City: | FREDERICKTOWN | ||||||||
State: | PA | ||||||||
PostalCode: | 153332114 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7246326801 | ||||||||
FaxNumber: | 7246326312 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/11/2005 | ||||||||
LastUpdateDate: | 06/09/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MARTOS | ||||||||
AuthorizedOfficialFirstName: | PATRICIA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR,FINANCE/PERSONNEL | ||||||||
AuthorizedOfficialTelephone: | 7246326801 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 1007288440027 | 05 | PA |   | MEDICAID | 903283 | 01 | PA | HIGHMARK | OTHER | 903283 | 01 | PA | HGSA - MEDICARE | OTHER |