=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366439580
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELK REGIONAL PROFESSIONAL GROUP, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2005
-----------------------------------------------------
Last Update Date | 07/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 COBB ST
-----------------------------------------------------
City | JOHNSONBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15845-1209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-965-2857
-----------------------------------------------------
Fax | 814-965-2523
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 COBB ST
-----------------------------------------------------
City | JOHNSONBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15845-1209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-965-2857
-----------------------------------------------------
Fax | 814-965-2523
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT, ERPG
-----------------------------------------------------
Name | RITA V OLSZEWSKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 814-788-8580
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------