Basic Information
| Provider Information | |||||||||
| NPI: | 1700157492 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ERIE COUNTY OFFICE OF AUDITOR | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ERIE COUNTY GENERAL HEALTH DISTRICT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 420 SUPERIOR ST | ||||||||
| Address2: | |||||||||
| City: | SANDUSKY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448701849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196265623 | ||||||||
| FaxNumber: | 4196268778 | ||||||||
| Practice Location | |||||||||
| Address1: | 420 SUPERIOR ST | ||||||||
| Address2: | |||||||||
| City: | SANDUSKY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448701849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196265623 | ||||||||
| FaxNumber: | 4196268778 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2012 | ||||||||
| LastUpdateDate: | 02/21/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 02/11/2014 | ||||||||
| NPIReactivationDate: | 02/21/2014 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PALMUCCI | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/CFO | ||||||||
| AuthorizedOfficialTelephone: | 4196265623 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 361972 | 01 | OH | MEDICARE CMS CERTIFICATION NUMBER | OTHER | 0051809 | 05 | OH | MEDICAID |