Basic Information
| Provider Information | |||||||||
| NPI: | 1326427196 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELK REGIONAL HEALTH CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PENN HIGHLANDS ELK ANESTHESIA SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 763 JOHNSONBURG RD | ||||||||
| Address2: | |||||||||
| City: | SAINT MARYS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158573417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143754200 | ||||||||
| FaxNumber: | 8143754232 | ||||||||
| Practice Location | |||||||||
| Address1: | 763 JOHNSONBURG RD | ||||||||
| Address2: | |||||||||
| City: | SAINT MARYS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158573417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004465090 | ||||||||
| FaxNumber: | 8143396165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2015 | ||||||||
| LastUpdateDate: | 06/10/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | CHAPMAN | ||||||||
| AuthorizedOfficialFirstName: | BRADLEY | ||||||||
| AuthorizedOfficialMiddleName: | JOSEPH | ||||||||
| AuthorizedOfficialTitleorPosition: | PRES/AUTH OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 8147888550 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ELK REGIONAL HEALTH CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 419584 | 01 | PA | MC PTAN | OTHER | 100729260 | 05 | PA | MEDICAID |