Basic Information
Provider Information | |||||||||
NPI: | 1821038134 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SHARON REGIONAL HEALTH SYSTEM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SRHS BEHAVIORAL SPECIALISTS | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 699 E STATE ST | ||||||||
Address2: |   | ||||||||
City: | SHARON | ||||||||
State: | PA | ||||||||
PostalCode: | 161462057 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7249833817 | ||||||||
FaxNumber: | 7249833941 | ||||||||
Practice Location | |||||||||
Address1: | 740 E STATE ST | ||||||||
Address2: | BEHAVIORAL HEALTH DEPT. | ||||||||
City: | SHARON | ||||||||
State: | PA | ||||||||
PostalCode: | 161463328 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7249835439 | ||||||||
FaxNumber: | 7249835661 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/07/2006 | ||||||||
LastUpdateDate: | 08/13/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CHROBAK | ||||||||
AuthorizedOfficialFirstName: | JEFF | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, FINANCE | ||||||||
AuthorizedOfficialTelephone: | 7249833815 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SHARON REGIONAL HEALTH SYSTEM | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0802X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | 2084P0804X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 104100000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |   | 103TC0700X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 1041C0700X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 363LP0808X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363AM0700X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 163W00000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse |   | 2084P0800X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 1325079 | 01 |   | HIGHMARK (BEHAV HEALTH) | OTHER |