1588662936 NPI number — LAUREL WOOD CARE CENTER, LLC

Table of content: HETAL RAY MD (NPI 1669976031)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588662936 NPI number — LAUREL WOOD CARE CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAUREL WOOD CARE CENTER, LLC
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:
LAUREL WOOD CARE CENTER
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:
1588662936
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
209 SIGMA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PITTSBURGH
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15238-2826
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
412-963-9150
Provider Business Mailing Address Fax Number:
412-963-6676

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 WOODMONT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15905-1342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-255-1488
Provider Business Practice Location Address Fax Number:
814-255-2293
Provider Enumeration Date:
07/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HENNELL
Authorized Official First Name:
HERBERT
Authorized Official Middle Name:
H
Authorized Official Title or Position:
VICE PRESIDENT OF REIMBURSEMENT
Authorized Official Telephone Number:
412-963-9150

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  380502 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0548 . This is a "SECURITY BLUE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1399778 . This is a "UMWA PROVIDER NUMBER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 071007900 . This is a "FEDERAL BLACK LUNG PROGRA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000114520 . This is a "UNISON (MED PLUS/3 RIVERS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1007294850003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0548 . This is a "BLUE CROSS PROVIDER NO." identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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