Basic Information
| Provider Information | |||||||||
| NPI: | 1386725182 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UPMC CHAUTAUQUA AT WCA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE WOMAN'S CHRISTIAN ASSOCIATION OF JAMESTOWN, N.Y. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 840 | ||||||||
| Address2: | 207 FOOTE AVE. | ||||||||
| City: | JAMESTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147020840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7164857892 | ||||||||
| FaxNumber: | 7164871802 | ||||||||
| Practice Location | |||||||||
| Address1: | 207 FOOTE AVE | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147017077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7164870141 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 01/27/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DINGER | ||||||||
| AuthorizedOfficialFirstName: | BRADLEY | ||||||||
| AuthorizedOfficialMiddleName: | NELSON | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8148773739 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | N | Hospital Units | Psychiatric Unit | 276400000X | N | Hospital Units | Rehabilitation, Substance Use Disorder Unit | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 03169151 | 05 | NY | MEDICAID |