=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649305293
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAINT CATHERINE PHYSICIAN SERVICES PCP OF PENNSYLVANIA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 411 SHENANDOAH RD
-----------------------------------------------------
City | RINGTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17967-9432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-889-3103
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 BROAD ST
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17921-2147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-875-6815
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | CRAIG HOOVER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 570-875-2000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------