Basic Information
| Provider Information | |||||||||
| NPI: | 1245621440 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALLEGHENY CLINIC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALLEGHENY HEALTH NETWORK - SLIPPERY ROCK PRIMARY CARE | ||||||||
| 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: | 4123305844 | ||||||||
| Practice Location | |||||||||
| Address1: | 621 KELLY BLVD | ||||||||
| Address2: | |||||||||
| City: | SLIPPERY ROCK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 160578523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7247944009 | ||||||||
| FaxNumber: | 7247944099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2015 | ||||||||
| LastUpdateDate: | 11/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | WALTEMIRE | ||||||||
| AuthorizedOfficialFirstName: | CINDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 4123305864 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.