Healthcare Provider Details

I. General information

NPI: 1285777136
Provider Name (Legal Business Name): SEWICKLEY PRIMARY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 10/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 BROAD ST SUITE 4B - 4TH FLOOR
SEWICKLEY PA
15143-1652
US

IV. Provider business mailing address

5626 OBERLIN DR SUITE 110
SAN DIEGO CA
92121-1705
US

V. Phone/Fax

Practice location:
  • Phone: 412-741-0985
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License NumberMD045483L
License Number StatePA

VIII. Authorized Official

Name: KENNY HEINE
Title or Position: DIR. OF OPERATIONS
Credential:
Phone: 858-625-2990