Healthcare Provider Details

I. General information

NPI: 1699153247
Provider Name (Legal Business Name): CONCORDIA PHYSICIAN PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2015
Last Update Date: 05/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 MARWOOD ROAD #5000
CABOT PA
16023-2245
US

IV. Provider business mailing address

112 MARWOOD ROAD #5000
CABOT PA
16023-2245
US

V. Phone/Fax

Practice location:
  • Phone: 724-352-4448
  • Fax: 724-352-4412
Mailing address:
  • Phone: 724-352-4448
  • Fax: 724-352-4412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. KEITH E FRNDAK
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 724-352-1571