Basic Information
| Provider Information | |||||||||
| NPI: | 1982668885 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELK REGIONAL PROFESSIONAL GROUP, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ERPG COMPREHENSIVE CARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 763 JOHNSONBURG RD | ||||||||
| Address2: | |||||||||
| City: | ST MARYS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158573417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147888580 | ||||||||
| FaxNumber: | 8147888042 | ||||||||
| Practice Location | |||||||||
| Address1: | 104 METOXET STREET | ||||||||
| Address2: | |||||||||
| City: | RIDGWAY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 15853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147885456 | ||||||||
| FaxNumber: | 8147727278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | OLSZEWSKI | ||||||||
| AuthorizedOfficialFirstName: | RITA | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8147888580 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207Q00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207RC0000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207V00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208600000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 363A00000X | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0018592850033 | 05 | PA | MEDICAID |