Basic Information
| Provider Information | |||||||||
| NPI: | 1730108994 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLEARFIELD PROFESSIONAL GROUP, LTD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 TURNPIKE AVE | ||||||||
| Address2: | |||||||||
| City: | CLEARFIELD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168301229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147652412 | ||||||||
| FaxNumber: | 8147658807 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 TURNPIKE AVE | ||||||||
| Address2: | |||||||||
| City: | CLEARFIELD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168301229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147652412 | ||||||||
| FaxNumber: | 8147658807 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 01/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | WITHEROW | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | BLAIR | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8147655796 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0011097860011 | 05 | PA | MEDICAID |