Healthcare Provider Details

I. General information

NPI: 1164064002
Provider Name (Legal Business Name): CENTERVILLE CLINICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2019
Last Update Date: 10/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CENTERVILLE CLINICS-DONORA FAMILY MEDICINE 718 MCKEAN AVENUE
DONORA PA
15033-1061
US

IV. Provider business mailing address

CENTERVILLE CLINICS INC 1070 OLD NATIONAL PIKE ROAD
FREDERICKTOWN PA
15333-2114
US

V. Phone/Fax

Practice location:
  • Phone: 724-379-4401
  • Fax:
Mailing address:
  • Phone: 724-632-6801
  • Fax: 724-632-6312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MR. BARRY R NICCOLAI
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 724-632-6801