Healthcare Provider Details

I. General information

NPI: 1225241805
Provider Name (Legal Business Name): CLARION UNIVERSITY OF PENNSYLVANIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 12/12/2019
Certification Date: 12/12/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15870 ROUTE 322 SUITE 2
CLARION PA
16214-6338
US

IV. Provider business mailing address

15870 ROUTE 322 SUITE 2
CLARION PA
16214-6338
US

V. Phone/Fax

Practice location:
  • Phone: 814-764-6066
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier1002302280003
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: ELIZABETH KUNDICK
Title or Position: FISCAL ADMINISTRATOR
Credential:
Phone: 814-297-8220