Basic Information
| Provider Information | |||||||||
| NPI: | 1992750731 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CONCENTRA MEDICAL CENTERS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 113 BUTLER AVE | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176016313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7173913087 | ||||||||
| FaxNumber: | 7173916752 | ||||||||
| Practice Location | |||||||||
| Address1: | 113 BUTLER AVE | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176016313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7173913087 | ||||||||
| FaxNumber: | 7173916752 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CALLAHAM | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | SCOTT | ||||||||
| AuthorizedOfficialTitleorPosition: | NURSE PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 7173913087 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CRNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | VP003515B | PA | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.