Basic Information
| Provider Information | |||||||||
| NPI: | 1114992484 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALLEGHENY MEDICAL PRACTICE NETWORK | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | EAST SUBURBAN OBGYN ASSSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2580 HAYMAKER RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | MONROEVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 151463518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4128567500 | ||||||||
| FaxNumber: | 4128566079 | ||||||||
| Practice Location | |||||||||
| Address1: | 2580 HAYMAKER RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | MONROEVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 151463518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4128567500 | ||||||||
| FaxNumber: | 4128566079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WALTEMIRE | ||||||||
| AuthorizedOfficialFirstName: | CINDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGED CARE SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 4123305523 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0017600750028 | 05 | PA | MEDICAID |