1326673690 NPI number — GLADE RUN MEDICAL ASSOCIATES

Table of content: (NPI 1326673690)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326673690 NPI number — GLADE RUN MEDICAL ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLADE RUN MEDICAL ASSOCIATES
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:
1326673690
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 NOLTE DR
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:
16201-7111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-543-8500
Provider Business Mailing Address Fax Number:
724-543-8616

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 MEDICAL ARTS BLDG STE 660
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:
16201-7110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-548-3884
Provider Business Practice Location Address Fax Number:
724-548-3885
Provider Enumeration Date:
03/07/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KOCIOLA
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
724-543-8500

Provider Taxonomy Codes

  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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