Basic Information
| Provider Information | |||||||||
| NPI: | 1326242439 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRESQUE ISLE PSYCHIATRIC ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2808 STATE ST | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165081830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144562457 | ||||||||
| FaxNumber: | 8144567679 | ||||||||
| Practice Location | |||||||||
| Address1: | 5515 PEACH ST | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165092603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148688270 | ||||||||
| FaxNumber: | 8148688274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ALBAUGH | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | ANNE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8144562457 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 0018721420001 | 05 | PA | MEDICAID |