Basic Information
| Provider Information | |||||||||
| NPI: | 1104872936 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WINDBER HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WINDBER CARE PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1511 SCALP AVE | ||||||||
| Address2: | |||||||||
| City: | JOHNSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 159043315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142544207 | ||||||||
| FaxNumber: | 8142544733 | ||||||||
| Practice Location | |||||||||
| Address1: | 1511 SCALP AVE | ||||||||
| Address2: | |||||||||
| City: | JOHNSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 159043315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142544207 | ||||||||
| FaxNumber: | 8142544733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 06/10/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KURTZ | ||||||||
| AuthorizedOfficialFirstName: | TOM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT / CEO | ||||||||
| AuthorizedOfficialTelephone: | 8144673702 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WINDBER HOSPITAL, INC. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD060939L | PA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD434855 | PA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1794402 | 01 | PA | HIGHMARK | OTHER | 1007703740019 | 05 | PA | MEDICAID |