Basic Information
Provider Information | |||||||||
NPI: | 1154641082 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | REGIONAL HEALTH SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TOTAL CARE FAMILY MEDICINE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 717 STATE ST | ||||||||
Address2: | SUITE 16 LL | ||||||||
City: | ERIE | ||||||||
State: | PA | ||||||||
PostalCode: | 165011341 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8148777100 | ||||||||
FaxNumber: | 8148772939 | ||||||||
Practice Location | |||||||||
Address1: | 3330 PEACH ST | ||||||||
Address2: | SUITE 107 | ||||||||
City: | ERIE | ||||||||
State: | PA | ||||||||
PostalCode: | 165082769 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8144551014 | ||||||||
FaxNumber: | 8144555387 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2010 | ||||||||
LastUpdateDate: | 04/05/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROEBACK | ||||||||
AuthorizedOfficialFirstName: | JASON | ||||||||
AuthorizedOfficialMiddleName: | N | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8148774242 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | REGIONAL HEALTH SERVICES, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X |   |   | Y |   | Laboratories | Clinical Medical Laboratory |   |
No ID Information.