Basic Information
| Provider Information | |||||||||
| NPI: | 1477597896 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OCCUPATIONAL HEALTH CENTERS OF THE SOUTHWEST PA | ||||||||
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| OtherOrganizationName: | CONCENTRA MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5080 SPECTRUM DRIVE | ||||||||
| Address2: | SUITE 1200 WEST TOWER | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002323550 | ||||||||
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| Practice Location | |||||||||
| Address1: | 901 EAST JEFFERSON STREET | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022562281 | ||||||||
| FaxNumber: | 6022566199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 07/21/2010 | ||||||||
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| AuthorizedOfficialLastName: | FOGARTY | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | TOM | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VP / CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9723648103 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | OTC 679 | AZ | N | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | 261QX0100X | OTC-679 | AZ | N | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine | 261QH0100X | OTC-679 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
No ID Information.