Basic Information
| Provider Information | |||||||||
| NPI: | 1538223714 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAINT VINCENT HLTH CTR SPU | ||||||||
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| Mailing Information | |||||||||
| Address1: | 232 W 25TH ST | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165440002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144525000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 232 W 25TH ST | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165440002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144525000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 01/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 8144525111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAINT VINCENT HEALTH CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO, MHA | ||||||||
| NPICertificationDate: | 01/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 196001 | PA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 0072 | 01 | PA | HIGHMARK FACILITY NUMBER | OTHER | 1001625200022 | 05 | PA | MEDICAID |