Healthcare Provider Details

I. General information

NPI: 1235204611
Provider Name (Legal Business Name): CLEARFIELD JEFFERSON HEAD AND NECK SURGICAL ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 09/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

871 BEAVER DR
DU BOIS PA
15801-2511
US

IV. Provider business mailing address

871 BEAVER DR PO BOX 308
DU BOIS PA
15801-2511
US

V. Phone/Fax

Practice location:
  • Phone: 814-375-0455
  • Fax: 814-375-2721
Mailing address:
  • Phone: 814-375-0455
  • Fax: 814-375-2721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD038440L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAT006006
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAT006006
License Number StatePA

VIII. Authorized Official

Name: GREGORY JAMES ROSCOE
Title or Position: PRESIDENT
Credential: DMD, MD
Phone: 814-375-0455