Basic Information
Provider Information | |||||||||
NPI: | 1568181170 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | J C BLAIR MEMORIAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PENN HIGHLANDS FAMILY MEDICINE | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1225 WARM SPRINGS AVE | ||||||||
Address2: |   | ||||||||
City: | HUNTINGDON | ||||||||
State: | PA | ||||||||
PostalCode: | 166522350 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8146438315 | ||||||||
FaxNumber: | 8146430869 | ||||||||
Practice Location | |||||||||
Address1: | 1227 WARM SPRINGS AVE STE 302 | ||||||||
Address2: |   | ||||||||
City: | HUNTINGDON | ||||||||
State: | PA | ||||||||
PostalCode: | 166522300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8146438668 | ||||||||
FaxNumber: | 8146438771 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/25/2022 | ||||||||
LastUpdateDate: | 10/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HAWN | ||||||||
AuthorizedOfficialFirstName: | KATHY | ||||||||
AuthorizedOfficialMiddleName: | ANN | ||||||||
AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
AuthorizedOfficialTelephone: | 8146432290 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PENN HIGHLANDS HEALTHCARE | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208D00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |   | 363A00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363L00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 100768376 | 05 | PA |   | MEDICAID | 075036 | 01 | PA | MC PTAN | OTHER |