Basic Information
| Provider Information | |||||||||
| NPI: | 1669773594 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WINDBER HOSPITAL INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WINDBER PHYSICIAN GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 321 MAIN ST | ||||||||
| Address2: | SUITE 3G | ||||||||
| City: | JOHNSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 159011632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8145357576 | ||||||||
| FaxNumber: | 8145361369 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 SOMERSET AVE | ||||||||
| Address2: | |||||||||
| City: | WINDBER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 159631331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144674750 | ||||||||
| FaxNumber: | 8144674751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2010 | ||||||||
| LastUpdateDate: | 05/13/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LAROSSE | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8145357576 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1760595755 | 01 | PA | TAESUN MOON, DO | OTHER | 1457336042 | 01 | KIM R MARLEY MD | OTHER | 1568692549 | 01 | NATHANIEL SANN CRNP | OTHER |