Basic Information
Provider Information | |||||||||
NPI: | 1427195445 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OLEAN GENERAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BRADFORD REGIONAL MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 116 INTERSTATE PKWY | ||||||||
Address2: |   | ||||||||
City: | BRADFORD | ||||||||
State: | PA | ||||||||
PostalCode: | 167011036 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8143684143 | ||||||||
FaxNumber: | 8143685722 | ||||||||
Practice Location | |||||||||
Address1: | 116 INTERSTATE PKWY | ||||||||
Address2: |   | ||||||||
City: | BRADFORD | ||||||||
State: | PA | ||||||||
PostalCode: | 167011036 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8143684143 | ||||||||
FaxNumber: | 8143685722 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/31/2007 | ||||||||
LastUpdateDate: | 01/16/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRAUN | ||||||||
AuthorizedOfficialFirstName: | RICHARD | ||||||||
AuthorizedOfficialMiddleName: | G | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 7163756104 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/16/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 940460 | PA | Y |   | Hospital Units | Psychiatric Unit |   |
ID Information
ID | Type | State | Issuer | Description | 1007507650035 | 05 | PA |   | MEDICAID | 00407034 | 05 | NY |   | MEDICAID | 0907 | 01 | PA | HIGHMARK BC | OTHER | 1007507650034 | 05 | PA |   | MEDICAID | UPMC | 01 | PA | UPMC | OTHER |