Basic Information
| Provider Information | |||||||||
| NPI: | 1245775774 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALLEGHENY HEALTH NETWORK | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SLIPPERY ROCK PRIMARY CARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 621 KELLY BLVD | ||||||||
| Address2: | PO BOX 143 | ||||||||
| City: | SLIPPERY ROCK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 160578523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7247744009 | ||||||||
| FaxNumber: | 7247944099 | ||||||||
| Practice Location | |||||||||
| Address1: | 621 KELLY BLVD | ||||||||
| Address2: | |||||||||
| City: | SLIPPERY ROCK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 160578523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7247744009 | ||||||||
| FaxNumber: | 7247944099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2016 | ||||||||
| LastUpdateDate: | 12/19/2016 | ||||||||
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| AuthorizedOfficialLastName: | YEAGER | ||||||||
| AuthorizedOfficialFirstName: | LUCINDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7247944009 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | SP016893 | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.