Basic Information
| Provider Information | |||||||||
| NPI: | 1841290731 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTRY MEADOWS OF SOUTH HILLS ASSOCIATES | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SOUTH HILLS NURSING AND REHABILITIATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 830 CHERRY DR | ||||||||
| Address2: | |||||||||
| City: | HERSHEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170332007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175330723 | ||||||||
| FaxNumber: | 7175331014 | ||||||||
| Practice Location | |||||||||
| Address1: | 3590 WASHINGTON PIKE | ||||||||
| Address2: | |||||||||
| City: | BRIDGEVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150171047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4122572474 | ||||||||
| FaxNumber: | 4122570358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2005 | ||||||||
| LastUpdateDate: | 10/04/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MIZAK | ||||||||
| AuthorizedOfficialFirstName: | VINCENT | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP- FINANCE, ACCOUNTING, INFO SRVS | ||||||||
| AuthorizedOfficialTelephone: | 7175330723 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 125402 | PA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0009828380001 | 05 | PA | MEDICAID |