Basic Information
| Provider Information | |||||||||
| NPI: | 1134303233 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CCMH SURGICAL SPECIALISTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 EAST SECOND STREET | ||||||||
| Address2: | |||||||||
| City: | COUDERSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 16915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142749300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1001 EAST SECOND STREET | ||||||||
| Address2: | |||||||||
| City: | COUDERSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 16915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142749300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2007 | ||||||||
| LastUpdateDate: | 12/26/2007 | ||||||||
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| AuthorizedOfficialLastName: | PITCHFORD | ||||||||
| AuthorizedOfficialFirstName: | ED | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8142745216 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHARLES COLE MEMORIAL HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1867505 | 01 | PA | BLUE SHIELD PROVIDER # | OTHER |