Basic Information
| Provider Information | |||||||||
| NPI: | 1245245612 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEST PENN ALLEGHENY HEALTH SYSTEM INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ALLEGHENY GENERAL HOSPITAL ALLEGHENY VALLEY DIALYSIS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 320 E NORTH AVE | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152124756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4123593131 | ||||||||
| FaxNumber: | 4123594108 | ||||||||
| Practice Location | |||||||||
| Address1: | 1620 PACIFIC AVE | ||||||||
| Address2: | |||||||||
| City: | NATRONA HEIGHTS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150652101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7242244382 | ||||||||
| FaxNumber: | 7242247298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 06/01/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FRIES | ||||||||
| AuthorizedOfficialFirstName: | RICK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | WPAHS CFO | ||||||||
| AuthorizedOfficialTelephone: | 4123598550 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WEST PENN ALLEGHENY HEALTH SYSTEM INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 530101 | PA | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 1007277200103 | 05 | PA | MEDICAID | 1007508630045 | 05 | PA | MEDICAID |