Basic Information
| Provider Information | |||||||||
| NPI: | 1639122344 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WARREN CONVENIENT CARE PHYSICIANS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 232 LAKESIDE DR | ||||||||
| Address2: | |||||||||
| City: | HORSHAM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190442319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002478060 | ||||||||
| FaxNumber: | 2159572875 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 ARROWOOD DR | ||||||||
| Address2: | |||||||||
| City: | ITHACA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148501867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072744150 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | BYRNE | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8002478060 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02264982 | 05 | NY | MEDICAID |