Basic Information
| Provider Information | |||||||||
| NPI: | 1407188857 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WARREN GENERAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DETOX UNIT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | TWO CRESCENT PARK W | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 163652111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147233300 | ||||||||
| FaxNumber: | 8147238515 | ||||||||
| Practice Location | |||||||||
| Address1: | TWO CRESCENT PARK W | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 163652111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147233300 | ||||||||
| FaxNumber: | 8147238515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2010 | ||||||||
| LastUpdateDate: | 05/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SNYDER | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXEC. DIR FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 8147233300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WARREN GENERAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 276400000X | AJJ96601 | PA | Y | Hospital Units | Rehabilitation, Substance Use Disorder Unit |
ID Information
| ID | Type | State | Issuer | Description | 1254 | 01 | PA | HIGHMARK BLUE CROSS BLUE SHIELD | OTHER |