1730833724 NPI number — GRACE WARWICK

Table of content: GRACE WARWICK (NPI 1730833724)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730833724 NPI number — GRACE WARWICK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WARWICK
Provider First Name:
GRACE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1730833724
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
599 N CHURCH STREET
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
MOUNT PLEASANT
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15666-1004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-542-5349
Provider Business Mailing Address Fax Number:
724-542-4658

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 N PITTSBURGH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONNELLSVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15425-3220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-603-6200
Provider Business Practice Location Address Fax Number:
724-626-4480
Provider Enumeration Date:
02/08/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  SP025296 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 104032417 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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