1790943108 NPI number — CLEAR MED PROVIDER CORPORATION

Table of content: (NPI 1790943108)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790943108 NPI number — CLEAR MED PROVIDER CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLEAR MED PROVIDER CORPORATION
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:
CLEAR MED ENT
Provider Other Organization Name Type Code:
5
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:
1790943108
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
809 TURNPIKE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEARFIELD
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16830-1232
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-768-2356
Provider Business Mailing Address Fax Number:
814-768-2134

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
807 TURNPIKE AVE
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
CLEARFIELD
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16830-1239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-768-2822
Provider Business Practice Location Address Fax Number:
814-768-2821
Provider Enumeration Date:
06/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
OLSZEWSKI
Authorized Official First Name:
RITA
Authorized Official Middle Name:
V
Authorized Official Title or Position:
CLEAR MED ADMINISTRATOR
Authorized Official Telephone Number:
814-768-2356

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  MD430012 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0105X , with the licence number: MD055298L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: MA051554 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2158598 . This is a "HIGHMARK BCBS ASSIGNMENT ACCOUNT" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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