1235204611 NPI number — CLEARFIELD JEFFERSON HEAD AND NECK SURGICAL ASSOCIATES, INC.

Table of content: (NPI 1235204611)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235204611 NPI number — CLEARFIELD JEFFERSON HEAD AND NECK SURGICAL ASSOCIATES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLEARFIELD JEFFERSON HEAD AND NECK SURGICAL 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:
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:
1235204611
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
871 BEAVER DR
Provider Second Line Business Mailing Address:
PO BOX 308
Provider Business Mailing Address City Name:
DU BOIS
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15801-2511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-375-0455
Provider Business Mailing Address Fax Number:
814-375-2721

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
871 BEAVER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DU BOIS
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15801-2511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-375-0455
Provider Business Practice Location Address Fax Number:
814-375-2721
Provider Enumeration Date:
11/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROSCOE
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
814-375-0455

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  MD038440L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 231H00000X , with the licence number: AT006006 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 237700000X , with the licence number: AT006006 , 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: 1007698100009 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2036569 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2038288 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 219994 . This is a "HEALTHAMERICA/HEALTHASSURANCE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: CL4582 . This is a "RAILROAD MEDICARE PIN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 3489 . This is a "GEISINGER HEALTH PLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2031692 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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