Basic Information
| Provider Information | |||||||||
| NPI: | 1548594393 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAINT VINCENT MEDICAL EDUCATION AND RESEARCH INSTITUTE INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PORT ERIE FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3530 PEACH ST | ||||||||
| Address2: | SUITE LL1 | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165082768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148605036 | ||||||||
| FaxNumber: | 8148605050 | ||||||||
| Practice Location | |||||||||
| Address1: | 3413 CHERRY ST | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165082678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148605970 | ||||||||
| FaxNumber: | 8148688561 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2009 | ||||||||
| LastUpdateDate: | 09/28/2009 | ||||||||
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| AuthorizedOfficialLastName: | BALLMAN | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8144525296 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100772520 0054 | 05 | PA | MEDICAID |