Basic Information
| Provider Information | |||||||||
| NPI: | 1104881648 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GATEWAY AREA MEDICAL PCP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 635C MAPLE AVE | ||||||||
| Address2: | |||||||||
| City: | DU BOIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158012377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143711771 | ||||||||
| FaxNumber: | 8143714417 | ||||||||
| Practice Location | |||||||||
| Address1: | 635C MAPLE AVE | ||||||||
| Address2: | |||||||||
| City: | DU BOIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158012377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143711771 | ||||||||
| FaxNumber: | 8143714417 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 12/13/2010 | ||||||||
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| AuthorizedOfficialLastName: | NOWAK | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING DEPT | ||||||||
| AuthorizedOfficialTelephone: | 8143711771 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0010511850004 | 05 | PA | MEDICAID |