Basic Information
| Provider Information | |||||||||
| NPI: | 1245209170 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH NET | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1202 STATE ST | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165011914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144544530 | ||||||||
| FaxNumber: | 8144562375 | ||||||||
| Practice Location | |||||||||
| Address1: | 1202 STATE ST | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165011914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144544530 | ||||||||
| FaxNumber: | 8144562375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 11/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | ULMER | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8144544530 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1007543070013 | 05 | PA | MEDICAID |