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General NPI Number Information
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NPI Number | 1164064002
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Entity Type | Organization
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Legal Business Name | CENTERVILLE CLINICS INC
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Dates
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Enumeration Date | 10/11/2019
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Last Update Date | 10/11/2019
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Provider Practice Location Address
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Address Line | CENTERVILLE CLINICS-DONORA FAMILY MEDICINE 718 MCKEAN AVENUE
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City | DONORA
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State | PA
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Zip | 15033-1061
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Country | US
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Telephone | 724-379-4401
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Fax |
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Provider Business Mailing Address
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Address Line | CENTERVILLE CLINICS INC 1070 OLD NATIONAL PIKE ROAD
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City | FREDERICKTOWN
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State | PA
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Zip | 15333-2114
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Country | US
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Telephone | 724-632-6801
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Fax | 724-632-6312
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. BARRY R NICCOLAI
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Credential |
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Telephone | 724-632-6801
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QF0400X
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Taxonomy Name | Federally Qualified Health Center (FQHC)
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License Number |
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License Number State |
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