Basic Information
| Provider Information | |||||||||
| NPI: | 1255387015 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY MEDICINE OF WARREN, PA,PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 143 PLEASANT DR | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 163653371 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 143 PLEASANT DR | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 163653371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147263310 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 01/05/2010 | ||||||||
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| AuthorizedOfficialLastName: | BENGSTON | ||||||||
| AuthorizedOfficialFirstName: | PAT | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8147263310 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001181789 | 05 | PA | MEDICAID |