Basic Information
| Provider Information | |||||||||
| NPI: | 1497731038 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VINCENT | ||||||||
| FirstName: | CAROLE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1648 HUNTINGDON PIKE | ||||||||
| Address2: | MEDICAL STAFF OFFICE FIRST FLOOR | ||||||||
| City: | MEADOWBROOK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190468001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159383450 | ||||||||
| FaxNumber: | 2159383829 | ||||||||
| Practice Location | |||||||||
| Address1: | 1650 HUNTINGDON PIKE STE 154 | ||||||||
| Address2: | |||||||||
| City: | MEADOWBROOK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190468003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159383145 | ||||||||
| FaxNumber: | 2159383144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 10/24/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 25MB06398300 | NJ | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | DO00838 | RI | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | OS011914 | PA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 570032900 | 05 | MN | MEDICAID | 7842007 | 05 | NJ | MEDICAID |