1558394908 NPI number — OTOLARYNGOLOGY GROUP OF CENTRAL PENNSYLVANIA

Table of content: (NPI 1558394908)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558394908 NPI number — OTOLARYNGOLOGY GROUP OF CENTRAL PENNSYLVANIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OTOLARYNGOLOGY GROUP OF CENTRAL PENNSYLVANIA
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:
1558394908
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 592
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:
16830-0592
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-339-7101
Provider Business Mailing Address Fax Number:
814-339-6165

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2505 GREEN TECH DR
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
STATE COLLEGE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16803-2316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-231-7750
Provider Business Practice Location Address Fax Number:
814-371-7752
Provider Enumeration Date:
07/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KAO
Authorized Official First Name:
YI
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
814-339-7101

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0017302900002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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