Basic Information
| Provider Information | |||||||||
| NPI: | 1477784106 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLEAR MED PROVIDER CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CLEAR MED PODIATRY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 809 TURNPIKE AVE | ||||||||
| Address2: | |||||||||
| City: | CLEARFIELD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168301232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147682356 | ||||||||
| FaxNumber: | 8147682134 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 TURNPIKE AVE | ||||||||
| Address2: | |||||||||
| City: | CLEARFIELD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168301233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147652006 | ||||||||
| FaxNumber: | 8147658807 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2009 | ||||||||
| LastUpdateDate: | 08/02/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OLSZEWSKI | ||||||||
| AuthorizedOfficialFirstName: | RITA | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | CLEAR MED ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8147682356 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CLEARFIELD HOSPITAL | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP1100X | N | Ambulatory Health Care Facilities | Clinic/Center | Podiatric | 213ES0103X | SC005951 | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2125484 | 01 | PA | HIGHMARK ASSIGNMENT ACCOUNT | OTHER |