Basic Information
| Provider Information | |||||||||
| NPI: | 1104906874 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAINT VINCENT MEDICAL EDUCATION AND RESEARCH INSTITUTE | ||||||||
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| OtherOrganizationName: | SAINT VINCENT SURGICAL ONCOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3530 PEACH ST | ||||||||
| Address2: | SUITE LL1 | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165082768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148605000 | ||||||||
| FaxNumber: | 8148605050 | ||||||||
| Practice Location | |||||||||
| Address1: | 145 W 23RD ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165022858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144518008 | ||||||||
| FaxNumber: | 8144561528 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BOATMAN | ||||||||
| AuthorizedOfficialFirstName: | DANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8144525264 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086X0206X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1007725200053 | 05 | PA | MEDICAID |