Basic Information
| Provider Information | |||||||||
| NPI: | 1326076951 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARBON MEDICAL ASSOC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 218A DELAWARE AVE | ||||||||
| Address2: | |||||||||
| City: | PALMERTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180711813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108266353 | ||||||||
| FaxNumber: | 6108266359 | ||||||||
| Practice Location | |||||||||
| Address1: | 218A DELAWARE AVE | ||||||||
| Address2: | |||||||||
| City: | PALMERTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180711813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108266353 | ||||||||
| FaxNumber: | 6108266359 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 11/08/2007 | ||||||||
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| AuthorizedOfficialLastName: | BOCK | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | SUSAN | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6108243752 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 363AM0700X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363LF0000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 869935 | 01 | PA | BLUE SHIELD GROUP NUMBER | OTHER | 02292600 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 0016426800005 | 05 | PA | MEDICAID |