=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902876212
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SCAC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2006
-----------------------------------------------------
Last Update Date | 07/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 BRANDT DRIVE SUITE 101
-----------------------------------------------------
City | CRANBERRY TWP
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-772-1766
-----------------------------------------------------
Fax | 724-772-5947
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 BRANDT DRIVE SUITE 101
-----------------------------------------------------
City | CRANBERRY TWP
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-772-1766
-----------------------------------------------------
Fax | 724-772-5947
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICIAN
-----------------------------------------------------
Name | WILLIAM CLARK CHRISTIE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 724-772-1766
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 16591501
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------