=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518225127
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FEDERAL BUREAU OF PRISONS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2012
-----------------------------------------------------
Last Update Date | 05/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 772 SAINT JOSEPH ST
-----------------------------------------------------
City | LORETTO
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15940-7006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-471-1579
-----------------------------------------------------
Fax | 814-471-1596
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 772 SAINT JOSEPH ST
-----------------------------------------------------
City | LORETTO
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15940-7006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-471-1579
-----------------------------------------------------
Fax | 814-471-1596
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HEALTH SERVICES ADMINISTRATOR/PA-C
-----------------------------------------------------
Name | MR. JEFFREY G. TRIMBATH
-----------------------------------------------------
Credential | PA-C/MPAS
-----------------------------------------------------
Telephone | 814-471-1579
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP0904X
-----------------------------------------------------
Taxonomy Name | Federal Public Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------