Basic Information
| Provider Information | |||||||||
| NPI: | 1821083700 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BUCKTAIL MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 PINE ST | ||||||||
| Address2: | |||||||||
| City: | RENOVO | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177641618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5709231000 | ||||||||
| FaxNumber: | 5709231812 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 PINE ST | ||||||||
| Address2: | |||||||||
| City: | RENOVO | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177641618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5709231000 | ||||||||
| FaxNumber: | 5709231812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2005 | ||||||||
| LastUpdateDate: | 04/01/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAIKEN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO/CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 5705316152 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 04/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 549601 | PA | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 1007644390002 | 05 | PA | MEDICAID | 1007644390004 | 05 | PA | MEDICAID | 1007644390003 | 05 | PA | MEDICAID | 1007644390010 | 05 | PA | MEDICAID | 1007644390007 | 05 | PA | MEDICAID |