Basic Information
| Provider Information | |||||||||
| NPI: | 1932382058 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHARLES COLE MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHAMPION ORTHOPEDICS & SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 EAST SECOND STREET | ||||||||
| Address2: | |||||||||
| City: | COUDERSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 16915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142749300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3132 ROUTE 417 | ||||||||
| Address2: | |||||||||
| City: | OLEAN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147601835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163723212 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2007 | ||||||||
| LastUpdateDate: | 05/10/2010 | ||||||||
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| AuthorizedOfficialLastName: | PITCHFORD | ||||||||
| AuthorizedOfficialFirstName: | ED | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8142745216 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 001738910 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER |