Basic Information
| Provider Information | |||||||||
| NPI: | 1912972563 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALLEGHENY MEDICAL PRACTICE NETWORK | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PRIMARY CARE PROFESSIONALS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 160 GALLERY DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MC MURRAY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153172690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249417144 | ||||||||
| FaxNumber: | 7249417625 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 GALLERY DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MC MURRAY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153172690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249417144 | ||||||||
| FaxNumber: | 7249417625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 08/15/2011 | ||||||||
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| AuthorizedOfficialLastName: | WALTEMIRE | ||||||||
| AuthorizedOfficialFirstName: | CINDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGED CARE SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 4123305523 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0017600750028 | 05 | PA | MEDICAID |