=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609990282
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ID CARE AND TRAVEL HEALTH OF NORTHWEST PA, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 764 KENNEDY ST SUITE 303
-----------------------------------------------------
City | MEADVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16335-2209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-373-2195
-----------------------------------------------------
Fax | 914-373-2197
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 764 KENNEDY ST SUITE 303
-----------------------------------------------------
City | MEADVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16335-2209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-373-2195
-----------------------------------------------------
Fax | 914-373-2197
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN-OWNER
-----------------------------------------------------
Name | DR. CAROL FELISA ENCARNACION
-----------------------------------------------------
Credential | M.D., M.P.H.
-----------------------------------------------------
Telephone | 814-373-2195
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number | MD420301
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------