Basic Information
| Provider Information | |||||||||
| NPI: | 1881897304 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELK REGIONAL PROFESSIONAL GROUP, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BENNETT'S VALLEY LAB | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 763 JOHNSONBURG RD | ||||||||
| Address2: | |||||||||
| City: | SAINT MARYS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158573417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147888580 | ||||||||
| FaxNumber: | 8147888042 | ||||||||
| Practice Location | |||||||||
| Address1: | 18457 BENNETT'S VALLEY HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | WEEDVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 15868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147875800 | ||||||||
| FaxNumber: | 8147875972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | OLSZEWSKI | ||||||||
| AuthorizedOfficialFirstName: | RITA | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8147888580 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 028019 | PA | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.