Basic Information
Provider Information | |||||||||
NPI: | 1285639278 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ELK REGIONAL HEALTH CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 763 JOHNSONBURG RD | ||||||||
Address2: |   | ||||||||
City: | ST MARYS | ||||||||
State: | PA | ||||||||
PostalCode: | 158573417 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8147888000 | ||||||||
FaxNumber: | 8147888234 | ||||||||
Practice Location | |||||||||
Address1: | 763 JOHNSONBURG RD | ||||||||
Address2: |   | ||||||||
City: | ST MARYS | ||||||||
State: | PA | ||||||||
PostalCode: | 158573417 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8147888000 | ||||||||
FaxNumber: | 8147888234 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/16/2005 | ||||||||
LastUpdateDate: | 07/25/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MACDONALD | ||||||||
AuthorizedOfficialFirstName: | LAURIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 8147888743 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 010901 | PA | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 1007292600030 | 05 | PA |   | MEDICAID | 0057 | 01 | PA | HIGHMARK BLUE CROSS | OTHER | 1007292600027 | 05 | PA |   | MEDICAID |