Basic Information
| Provider Information | |||||||||
| NPI: | 1194049098 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIMARY CARE GROUP 11, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | JRMC MCMURRAY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 ALLEGHENY CTR FL 7 | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152125255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4123305861 | ||||||||
| FaxNumber: | 4123305544 | ||||||||
| Practice Location | |||||||||
| Address1: | 455 VALLEY BROOK RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MC MURRAY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153173367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249415588 | ||||||||
| FaxNumber: | 7249411458 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2010 | ||||||||
| LastUpdateDate: | 10/06/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NOEL | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 4123305861 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JEFFERSON REGIONAL MEDICAL CENTER | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS-003395-L | PA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207RP1001X | MD018247E | PA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.