Basic Information
| Provider Information | |||||||||
| NPI: | 1184605438 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTERVILLE CLINICS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1070 OLD NATIONAL PIKE | ||||||||
| Address2: | |||||||||
| City: | FREDERICKTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153332114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7246326801 | ||||||||
| FaxNumber: | 7246326312 | ||||||||
| Practice Location | |||||||||
| Address1: | 1070 OLD NATIONAL PIKE | ||||||||
| Address2: | |||||||||
| City: | FREDERICKTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153332114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7246326801 | ||||||||
| FaxNumber: | 7246326312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2005 | ||||||||
| LastUpdateDate: | 01/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | MARTOS | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE/PERSONNEL | ||||||||
| AuthorizedOfficialTelephone: | 7246326801 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207KA0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | Allergy | 207N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208800000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 124Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dental Hygienist | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 032094 | 01 | PA | HGSA MEDICARE | OTHER | 031218 | 01 | PA | HGSA MEDICARE | OTHER | 030163 | 01 | PA | HGSA MEDICARE | OTHER | 031216 | 01 | PA | HGSA MEDICARE | OTHER | 031395 | 01 | PA | HGSA MEDICARE | OTHER | 1007288440027 | 05 | PA | MEDICAID | 031221 | 01 | PA | HGSA MEDICARE | OTHER | 032095 | 01 | PA | HGSA MEDICARE | OTHER | 026902 | 01 | PA | HGSA MEDICARE | OTHER |