Basic Information
| Provider Information | |||||||||
| NPI: | 1700084944 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UPMC HANOVER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | UPMC PINNACLE HANOVER | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 300 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | HANOVER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173312297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7176373711 | ||||||||
| FaxNumber: | 7176332217 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | HANOVER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173312297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7176373711 | ||||||||
| FaxNumber: | 7176332217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2007 | ||||||||
| LastUpdateDate: | 08/19/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MULLER | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 7173162153 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 081801 | PA | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 1007440330018 | 05 | PA | MEDICAID |