Basic Information
| Provider Information | |||||||||
| NPI: | 1366819880 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHARLES COLE MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHAMPION ORTHOPEDICS AND SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 E 2ND ST | ||||||||
| Address2: | |||||||||
| City: | COUDERSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 169158161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142745320 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1001 E 2ND ST | ||||||||
| Address2: | |||||||||
| City: | COUDERSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 169158161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142745320 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2015 | ||||||||
| LastUpdateDate: | 09/01/2015 | ||||||||
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| AuthorizedOfficialLastName: | PITCHFORD | ||||||||
| AuthorizedOfficialFirstName: | ED | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 8142749300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.