1699862847 NPI number — LAUREL RIDGE SURGICAL ASSOCIATES, INC.

Table of content: (NPI 1699862847)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699862847 NPI number — LAUREL RIDGE SURGICAL ASSOCIATES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAUREL RIDGE 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:
1699862847
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
196 W MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UNIONTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15401-5537
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-439-1020
Provider Business Mailing Address Fax Number:
724-434-5485

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
196 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNIONTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15401-5537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-439-1020
Provider Business Practice Location Address Fax Number:
724-434-5485
Provider Enumeration Date:
10/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REILLY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
724-439-1020

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)

  • Identifier: 0010549730006 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1395403 . This is a "UMWA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 103737 . This is a "UPMC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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