Basic Information
| Provider Information | |||||||||
| NPI: | 1821419813 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAINT VINCENT DIABETES RESOURCE OUTPATIENT NUTRITION CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 145 W 23RD ST | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165440002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144527354 | ||||||||
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| Practice Location | |||||||||
| Address1: | 145 W 23RD ST | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165440002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144527354 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2013 | ||||||||
| LastUpdateDate: | 12/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | WHALEN | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 8144525111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAINT VINCENT HEALTH CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PHD, FACHE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 0072 | 01 | PA | HIGHMARK FACILITY NUMBER | OTHER | 1001625200025 | 05 | PA | MEDICAID |