1497751002 NPI number — KISKI VALLEY COMMUNITY MEDICINE, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497751002 NPI number — KISKI VALLEY COMMUNITY MEDICINE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KISKI VALLEY COMMUNITY MEDICINE, PC
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:
1497751002
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
310 SOUTH SECOND STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APOLLO
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15613-1111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-478-2999
Provider Business Mailing Address Fax Number:
724-478-3005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 S 2ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
APOLLO
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15613-1150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-478-2999
Provider Business Practice Location Address Fax Number:
724-478-3005
Provider Enumeration Date:
06/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KUPAS
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
724-478-2999

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  0S008135L , 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: 0015371560003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 257824 . This is a "HIGHMARK" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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