Basic Information
| Provider Information | |||||||||
| NPI: | 1417132580 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTERVILLE CLINICS, INC BLENDED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1070 OLD NATIONAL PIKE | ||||||||
| Address2: | |||||||||
| City: | FREDERICKTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153332114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7246326801 | ||||||||
| FaxNumber: | 7246326312 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 W GEORGE ST | ||||||||
| Address2: | |||||||||
| City: | CARMICHAELS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153201325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249665081 | ||||||||
| FaxNumber: | 7249669002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2008 | ||||||||
| LastUpdateDate: | 01/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | MARTOS | ||||||||
| AuthorizedOfficialFirstName: | PATTY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR FINANCE/PERSONNEL | ||||||||
| AuthorizedOfficialTelephone: | 7246326801 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | PA | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 328834A764918 | 01 | PA | VALUE BEHAVIOR HEALTH | OTHER | 1007288440093 | 05 | PA | MEDICAID |