1104840750 NPI number — HCF OF CORRY, INC.

Table of content: JAYSON VAZQUEZ MERCADO M.D. (NPI 1740224534)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104840750 NPI number — HCF OF CORRY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HCF OF CORRY, INC.
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:
CORRY MANOR
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:
1104840750
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 SHAWNEE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIMA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45805-3583
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-999-2010
Provider Business Mailing Address Fax Number:
419-999-6284

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
640 WORTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORRY
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16407-8515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-664-9606
Provider Business Practice Location Address Fax Number:
814-665-0036
Provider Enumeration Date:
07/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
UNVERFERTH
Authorized Official First Name:
CHAD
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
VICE PRESIDENT - FINANCE & CFO
Authorized Official Telephone Number:
419-999-2010

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  815002 , 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: 00568236 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0986 . This is a "SECURITY BLUE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0019250400001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 305043 . This is a "ADVANTRA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 000000087154 . This is a "THREE RIVERS/UNISON" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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