Basic Information
| Provider Information | |||||||||
| NPI: | 1932129368 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL GROUP OF CORRY, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 YORK ST | ||||||||
| Address2: | |||||||||
| City: | CORRY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 164071412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8146648686 | ||||||||
| FaxNumber: | 8146649826 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 YORK ST | ||||||||
| Address2: | |||||||||
| City: | CORRY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 164071412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8146648686 | ||||||||
| FaxNumber: | 8146649826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 05/21/2010 | ||||||||
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| AuthorizedOfficialLastName: | ALBRIGHT | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8146648686 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 463990 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 0006472600016 | 05 | PA | MEDICAID |