MEDICARE: BROAD TOP AREA MEDICAL CENTER, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1174039408
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROAD TOP AREA MEDICAL CENTER, INC

Provider Business Mailing Address
First Line	:	PO BOX 127
Second Line	:
City	:	BROAD TOP
State	:	PA
Zip	:	16621-0127
Country	:	US
Telephone Number	:	814-635-7351
Fax Number	:	814-635-7354

Provider Business Practice Location Address
First Line	:	95 S PARK ST
Second Line	:
City	:	MOUNT UNION
State	:	PA
Zip	:	17066-1334
Country	:	US
Telephone Number	:	815-542-8627
Fax Number	:	814-542-5444

Authorized Official
Title or Position	:	CEO
Name	:	JOHN ROTH
Credential	:	MD
Telephone Number	:	814-635-2916

Provider Enumeration Date	:	12/22/2017
Last Update Date	:	04/22/2021

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