Basic Information
| Provider Information | |||||||||
| NPI: | 1669647210 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAINT VINCENT ENDOSCOPY CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 415357 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022415357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155899000 | ||||||||
| FaxNumber: | 2155899030 | ||||||||
| Practice Location | |||||||||
| Address1: | 2501 W 12TH ST | ||||||||
| Address2: | SUITE 8 | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165054527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155899000 | ||||||||
| FaxNumber: | 2155899030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2008 | ||||||||
| LastUpdateDate: | 11/23/2009 | ||||||||
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| AuthorizedOfficialLastName: | SABLYAK | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 2155899001 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 82192 | 01 | AAAHC ACCREDITATION | OTHER | 100246794 0001 | 05 | PA | MEDICAID |