Healthcare Provider Details

I. General information

NPI: 1245294693
Provider Name (Legal Business Name): CENTRE MEDICAL AND SURGICAL ASSOCIATES, P.C., DEPT OF OB/GYN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 E PARK AVE SUITE 301
STATE COLLEGE PA
16803-6706
US

IV. Provider business mailing address

1850 E PARK AVE SUITE 301
STATE COLLEGE PA
16803-6706
US

V. Phone/Fax

Practice location:
  • Phone: 814-237-3470
  • Fax: 814-237-2035
Mailing address:
  • Phone: 814-237-3470
  • Fax: 814-237-2035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD027554E
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier421802
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerHIGHMARK BLUE SHIELD

VIII. Authorized Official

Name: JOHN J. MCQUEARY
Title or Position: COO/ADMINISTRATIVE DIRECTOR
Credential:
Phone: 814-234-4753