Basic Information
| Provider Information | |||||||||
| NPI: | 1538167341 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDONOUGH | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WOLFE | ||||||||
| OtherFirstName: | JAMIE | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2101 NAGLE RD | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165102189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148777078 | ||||||||
| FaxNumber: | 8148995484 | ||||||||
| Practice Location | |||||||||
| Address1: | 2101 NAGLE RD | ||||||||
| Address2: | UPMC CENTERS FOR REHAB SERVICES | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165102189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148777078 | ||||||||
| FaxNumber: | 8148995484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 12/13/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT013867L | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1011581100001 | 05 | PA | MEDICAID | 00027021401 | 01 | NY | UNIVERA | OTHER | 3762785 | 01 | PA | AETNA | OTHER | P00170352 | 01 | PA | RR MEDICARE | OTHER | 1672791 | 01 | PA | BLUE SHIELD | OTHER |