1114403037 NPI number — GLADE RUN MEDICAL ASSOCIATES, INC.

Table of content: (NPI 1114403037)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114403037 NPI number — GLADE RUN MEDICAL ASSOCIATES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLADE RUN MEDICAL ASSOCIATES, 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:
Provider Other Organization Name Type Code:
6
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:
1114403037
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 MEDICAL ARTS BLDG STE 710
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KITTANNING
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16201-7141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-543-8626
Provider Business Mailing Address Fax Number:
724-543-8736

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 NOLTE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KITTANNING
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16201-7111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-545-3588
Provider Business Practice Location Address Fax Number:
724-545-3589
Provider Enumeration Date:
07/13/2018

Additional Information

Authorized Official

Authorized Official Last Name:
MILSOM
Authorized Official First Name:
PAMELA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
724-543-8670

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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