Basic Information
| Provider Information | |||||||||
| NPI: | 1922077205 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE WASHINGTON HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WASHINGTON HOSPITAL FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 95 LEONARD AVE | ||||||||
| Address2: | BLDG 2 | ||||||||
| City: | WASHINGTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153013368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7242233100 | ||||||||
| FaxNumber: | 7242233353 | ||||||||
| Practice Location | |||||||||
| Address1: | 95 LEONARD AVE | ||||||||
| Address2: | BLDG 2 | ||||||||
| City: | WASHINGTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153013368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7242233100 | ||||||||
| FaxNumber: | 7242233353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2006 | ||||||||
| LastUpdateDate: | 05/15/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MINTEER | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSOCIATE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7242233100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 119676300 | 01 | DEPT OF LABOR | OTHER | 904324 | 01 | HIGHMARK | OTHER | 010941730 | 01 | UMWA | OTHER |