1104906874 NPI number — SAINT VINCENT MEDICAL EDUCATION AND RESEARCH INSTITUTE

Table of content: (NPI 1104906874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104906874 NPI number — SAINT VINCENT MEDICAL EDUCATION AND RESEARCH INSTITUTE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAINT VINCENT MEDICAL EDUCATION AND RESEARCH INSTITUTE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SAINT VINCENT SURGICAL ONCOLOGY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104906874
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3530 PEACH ST
Provider Second Line Business Mailing Address:
SUITE LL1
Provider Business Mailing Address City Name:
ERIE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16508-2768
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-860-5000
Provider Business Mailing Address Fax Number:
814-860-5050

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
145 W 23RD ST
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
ERIE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16502-2858
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-451-8008
Provider Business Practice Location Address Fax Number:
814-456-1528
Provider Enumeration Date:
10/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOATMAN
Authorized Official First Name:
DANA
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
814-452-5264

Provider Taxonomy Codes

  • Taxonomy code: 2086X0206X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1007725200053 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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