Basic Information
Provider Information | |||||||||
NPI: | 1477617173 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SHARON REGIONAL HEALTH SYSTEM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SRHS CHATWOOD PT REHAB CTR | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 699 E STATE ST | ||||||||
Address2: |   | ||||||||
City: | SHARON | ||||||||
State: | PA | ||||||||
PostalCode: | 161462057 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7249833817 | ||||||||
FaxNumber: | 7249833941 | ||||||||
Practice Location | |||||||||
Address1: | 2380 HIGHLAND RD | ||||||||
Address2: |   | ||||||||
City: | HERMITAGE | ||||||||
State: | PA | ||||||||
PostalCode: | 161482819 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7249833960 | ||||||||
FaxNumber: | 7249835565 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/20/2006 | ||||||||
LastUpdateDate: | 11/17/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CHROBAK | ||||||||
AuthorizedOfficialFirstName: | JEFF | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT FOR FINANCE | ||||||||
AuthorizedOfficialTelephone: | 7249833815 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SHARON REGIONAL HEALTH SYSTEM | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | 261Q00000X | 196601 | PA | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
ID Information
ID | Type | State | Issuer | Description | 1000000590082 | 05 | PA |   | MEDICAID |