1629204060 NPI number — CLEAR MED PROVIDER GROUP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629204060 NPI number — CLEAR MED PROVIDER GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLEAR MED PROVIDER GROUP
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:
1629204060
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/10/2010
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:
2772 CECIL HURD HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAHAFFEY
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15757-6322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-277-4504
Provider Business Practice Location Address Fax Number:
814-277-6873
Provider Enumeration Date:
05/29/2009

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: 207Q00000X , with the licence number:  MD047546L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: MD031136L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • 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" .
  • Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0166056 . This is a "HIGHMARK" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 001829615 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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