Basic Information
Provider Information | |||||||||
NPI: | 1679566004 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ASSOCIATES CHIROPRACTIC CLINIC & REHABILITATION CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2275 SWALLOW HILL RD | ||||||||
Address2: | BUILDING 2600 | ||||||||
City: | PITTSBURGH | ||||||||
State: | PA | ||||||||
PostalCode: | 152201656 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4122794522 | ||||||||
FaxNumber: | 4122793416 | ||||||||
Practice Location | |||||||||
Address1: | 2275 SWALLOW HILL RD | ||||||||
Address2: | BUILDING 2600 | ||||||||
City: | PITTSBURGH | ||||||||
State: | PA | ||||||||
PostalCode: | 152201656 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4122794522 | ||||||||
FaxNumber: | 4122793416 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2005 | ||||||||
LastUpdateDate: | 11/03/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HIERONIMUS | ||||||||
AuthorizedOfficialFirstName: | GARY | ||||||||
AuthorizedOfficialMiddleName: | T. | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 4122794522 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | D.C. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor |   |
ID Information
ID | Type | State | Issuer | Description | 1404943 | 01 | PA | BS GROUP # | OTHER | 032360 | 01 | PA | MEDICARE GROUP NUMBER | OTHER |