=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770614919
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INDIANA REGIONAL MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2007
-----------------------------------------------------
Last Update Date | 07/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 835 HOSPITAL ROAD PEDIATRIC & ADOLESCENT DENTAL CLINIC
-----------------------------------------------------
City | INDIANA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15701-0788
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-357-6960
-----------------------------------------------------
Fax | 724-357-6961
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 835 HOSPITAL ROAD PO BOX 788
-----------------------------------------------------
City | INDIANA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15701-0788
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-357-7009
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | MR. MICHAEL F ICKOWSKI
-----------------------------------------------------
Credential | CPA, MBA
-----------------------------------------------------
Telephone | 724-357-7008
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 090701
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------