1376537431 NPI number — COUNTRYSIDE CONVALESCENT HOME LIMITED PARTNERSHIP

Table of content: (NPI 1376537431)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376537431 NPI number — COUNTRYSIDE CONVALESCENT HOME LIMITED PARTNERSHIP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTRYSIDE CONVALESCENT HOME LIMITED PARTNERSHIP
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:
Provider Other Organization Name Type Code:
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:
1376537431
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8221 LAMOR RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERCER
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16137-3163
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-431-0770
Provider Business Mailing Address Fax Number:
724-431-0764

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8221 LAMOR RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERCER
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16137-3163
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-431-0770
Provider Business Practice Location Address Fax Number:
724-431-0764
Provider Enumeration Date:
09/06/2005

Additional Information

Authorized Official

Authorized Official Last Name:
TACK
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
724-431-0770

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1121 . This is a "HIGHMARK BC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1501006 . This is a "GATEWAY HP" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0012990090001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 263249 . This is a "HEALTH AMERICA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 305354 . This is a "UPMC" identifier . This identifiers is of the category "OTHER".




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