Basic Information
| Provider Information | |||||||||
| NPI: | 1124324256 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLEAR MED PROVIDER CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CLEAR MED HOSPITALIST PROGRAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P O BOX 1260 | ||||||||
| Address2: | 809 TURNPIKE AVENUE | ||||||||
| City: | CLEARFIELD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168301232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004465090 | ||||||||
| FaxNumber: | 8143396165 | ||||||||
| Practice Location | |||||||||
| Address1: | 809 TURNPIKE AVE | ||||||||
| Address2: | |||||||||
| City: | CLEARFIELD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168301232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004465090 | ||||||||
| FaxNumber: | 8143396165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2011 | ||||||||
| LastUpdateDate: | 08/18/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCCONNELL | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8143756431 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 001829615 | 05 | PA | MEDICAID | 2002724 | 01 | PA | HIGHMARK ASSIGNMENT ACCOUNT | OTHER |