Basic Information
| Provider Information | |||||||||
| NPI: | 1467966853 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADDICTION WELLNESS SERVICES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3824 NORTHERN PIKE STE 600 | ||||||||
| Address2: | |||||||||
| City: | MONROEVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 151462156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4124570175 | ||||||||
| FaxNumber: | 4124570179 | ||||||||
| Practice Location | |||||||||
| Address1: | 5504 N 2ND ST | ||||||||
| Address2: | |||||||||
| City: | LOVES PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611115013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159974516 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2017 | ||||||||
| LastUpdateDate: | 01/29/2019 | ||||||||
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| AuthorizedOfficialLastName: | GOYAL | ||||||||
| AuthorizedOfficialFirstName: | GAGANDEEP | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2672264760 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP3000X | MD438154 | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | MD438154 | 01 | PA | PA LICENSE | OTHER | 036144684 | 01 | IL | IL LICENSE | OTHER |