Healthcare Provider Details

I. General information

NPI: 1477883429
Provider Name (Legal Business Name): UPMC PRESBYTERIAN SHADYSIDE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2010
Last Update Date: 01/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 BRADDOCK AVE
BRADDOCK PA
15104-1715
US

IV. Provider business mailing address

818 BRADDOCK AVE
BRADDOCK PA
15104-1715
US

V. Phone/Fax

Practice location:
  • Phone: 412-636-5187
  • Fax: 412-636-5248
Mailing address:
  • Phone: 412-636-5187
  • Fax: 412-636-5248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDS027386L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDS030969L
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDS037519
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1007360690004
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: MR. PAUL CASTILLO
Title or Position: CFO
Credential:
Phone: 412-647-7713