Basic Information
Provider Information | |||||||||
NPI: | 1962748095 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UPMC CHAUTAUQUA AT WCA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WOMANS CHRISTIAN ASSOCIATION HOSPITAL | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 207 FOOTE AVE | ||||||||
Address2: |   | ||||||||
City: | JAMESTOWN | ||||||||
State: | NY | ||||||||
PostalCode: | 147017077 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7164870141 | ||||||||
FaxNumber: | 7164872488 | ||||||||
Practice Location | |||||||||
Address1: | 207 FOOTE AVE | ||||||||
Address2: |   | ||||||||
City: | JAMESTOWN | ||||||||
State: | NY | ||||||||
PostalCode: | 147017077 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7164870141 | ||||||||
FaxNumber: | 7164872488 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/18/2012 | ||||||||
LastUpdateDate: | 01/27/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DINGER | ||||||||
AuthorizedOfficialFirstName: | BRADLEY | ||||||||
AuthorizedOfficialMiddleName: | NELSON | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 8148773739 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/27/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | 0602001H | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207X00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 208600000X | 0602001H | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 04104376 | 05 | NY |   | MEDICAID |