Basic Information
Provider Information | |||||||||
NPI: | 1568666949 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ELK REGIONAL PROFESSIONAL GROUP, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ECMA - RIDGWAY LAB | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 763 JOHNSONBURG RD | ||||||||
Address2: |   | ||||||||
City: | SAINT MARYS | ||||||||
State: | PA | ||||||||
PostalCode: | 158573417 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8147888580 | ||||||||
FaxNumber: | 8147888042 | ||||||||
Practice Location | |||||||||
Address1: | 123 SOUTH ST | ||||||||
Address2: |   | ||||||||
City: | RIDGWAY | ||||||||
State: | PA | ||||||||
PostalCode: | 158532008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8147817531 | ||||||||
FaxNumber: | 8147817494 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/12/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | OLSZEWSKI | ||||||||
AuthorizedOfficialFirstName: | RITA | ||||||||
AuthorizedOfficialMiddleName: | V | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 8147888580 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 028359 | PA | Y |   | Laboratories | Clinical Medical Laboratory |   |
No ID Information.