Basic Information
| Provider Information | |||||||||
| NPI: | 1952558207 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHARON REGIONAL HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SRHS PTH D&A PHP IN HERMITAGE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 699 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | SHARON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 161462057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249833817 | ||||||||
| FaxNumber: | 7249833941 | ||||||||
| Practice Location | |||||||||
| Address1: | 2375 GARDEN WAY | ||||||||
| Address2: | |||||||||
| City: | HERMITAGE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 161485209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249835448 | ||||||||
| FaxNumber: | 7249835446 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2008 | ||||||||
| LastUpdateDate: | 11/11/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHROBAK | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 7249833815 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SHARON REGIONAL HEALTH SYSTEM | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 437016 | PA | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 1000000590105 | 05 | PA | MEDICAID | 0925 | 01 | PA | HIGHMARK | OTHER |