Basic Information
| Provider Information | |||||||||
| NPI: | 1558394908 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OTOLARYNGOLOGY GROUP OF CENTRAL PENNSYLVANIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 592 | ||||||||
| Address2: | |||||||||
| City: | CLEARFIELD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168300592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143397101 | ||||||||
| FaxNumber: | 8143396165 | ||||||||
| Practice Location | |||||||||
| Address1: | 2505 GREEN TECH DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | STATE COLLEGE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168032316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142317750 | ||||||||
| FaxNumber: | 8143717752 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 06/30/2015 | ||||||||
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| AuthorizedOfficialLastName: | KAO | ||||||||
| AuthorizedOfficialFirstName: | YI | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8143397101 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 0017302900002 | 05 | PA | MEDICAID |