Basic Information
Provider Information | |||||||||
NPI: | 1730211855 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OCCUPATIONAL HEALTH CENTERS OF THE SOUTHWEST PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CONCENTRA MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5080 SPECTRUM DRIVE | ||||||||
Address2: | SUITE 1200 WEST TOWER | ||||||||
City: | ADDISON | ||||||||
State: | TX | ||||||||
PostalCode: | 75001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9727207768 | ||||||||
FaxNumber: | 2147754502 | ||||||||
Practice Location | |||||||||
Address1: | 4600 SOUTH PARK AVENUE | ||||||||
Address2: | SUITE 5 | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 85714 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5208899574 | ||||||||
FaxNumber: | 2147754502 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/12/2007 | ||||||||
LastUpdateDate: | 01/12/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ANDERSON | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR VP / CHIEF MEDICAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 9723648000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DO | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | 261QX0100X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine | 261QH0100X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
No ID Information.