Basic Information
| Provider Information | |||||||||
| NPI: | 1720040090 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH COLUMBIA MEDICAL OFFICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 390 | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178140390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5709256424 | ||||||||
| FaxNumber: | 5709255930 | ||||||||
| Practice Location | |||||||||
| Address1: | 4469 RED ROCK RD | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178147606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5709256424 | ||||||||
| FaxNumber: | 5709255930 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PRISUTA | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5709256424 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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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 | 1007396970001 | 05 | PA | MEDICAID | M2378 | 01 | RAILROAD MEDICARE | OTHER | C325 | 01 | GEISINGER HEALTH PLAN | OTHER | 506030 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 02283200 | 01 | PA | CAPITAL BLUE CROSS | OTHER |