Basic Information
Provider Information | |||||||||
NPI: | 1710056015 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CONEMAUGH HEALTH INITIATIVES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1086 FRANKLIN ST | ||||||||
Address2: |   | ||||||||
City: | JOHNSTOWN | ||||||||
State: | PA | ||||||||
PostalCode: | 159054305 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8144108300 | ||||||||
FaxNumber: | 8144108331 | ||||||||
Practice Location | |||||||||
Address1: | 3670 PORTAGE ST | ||||||||
Address2: |   | ||||||||
City: | PORTAGE | ||||||||
State: | PA | ||||||||
PostalCode: | 159466546 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8147369614 | ||||||||
FaxNumber: | 8147369783 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/08/2006 | ||||||||
LastUpdateDate: | 02/11/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LAMBERT | ||||||||
AuthorizedOfficialFirstName: | ELAINE | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8145341630 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | CB9772 | 01 | PA | RAILROAD MEDICARE | OTHER |