Basic Information
| Provider Information | |||||||||
| NPI: | 1114114626 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALLEGHENY CLINIC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALLEGHENY CENTER FOR DIGESTIVE HEALTH PHD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1307 FEDERAL ST | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152124769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4123598900 | ||||||||
| FaxNumber: | 4123599877 | ||||||||
| Practice Location | |||||||||
| Address1: | 1307 FEDERAL ST | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152124769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4123598900 | ||||||||
| FaxNumber: | 4123599877 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2007 | ||||||||
| LastUpdateDate: | 09/07/2016 | ||||||||
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| AuthorizedOfficialLastName: | LOVELACE | ||||||||
| AuthorizedOfficialFirstName: | TESHA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPEC | ||||||||
| AuthorizedOfficialTelephone: | 4123305187 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1007317140349 | 05 | PA | MEDICAID |