Basic Information
Provider Information | |||||||||
NPI: | 1720180136 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WEST PENN ALLEGHENY HEALTH SYSTEM, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | THE FOOT AND ANKLE INSTITUTE OF W. PA. | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2570 HAYMAKER RD OFC BLDG1 | ||||||||
Address2: | SUITE 211 | ||||||||
City: | MONROEVILLE | ||||||||
State: | PA | ||||||||
PostalCode: | 151463513 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4128587699 | ||||||||
FaxNumber: | 4128587696 | ||||||||
Practice Location | |||||||||
Address1: | 4800 FRIENDSHIP AVE | ||||||||
Address2: | SUITE N1 | ||||||||
City: | PITTSBURGH | ||||||||
State: | PA | ||||||||
PostalCode: | 152241722 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4126887580 | ||||||||
FaxNumber: | 4126819676 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/05/2006 | ||||||||
LastUpdateDate: | 12/09/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MENDICINO | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR, PRACTICE MANAGEMENT | ||||||||
AuthorizedOfficialTelephone: | 4128587691 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |   |
ID Information
ID | Type | State | Issuer | Description | 1007277200089 | 05 | PA |   | MEDICAID |