=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982635785
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEST BRANCH NEPHROLOGY ASSOCIATES LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2006
-----------------------------------------------------
Last Update Date | 03/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1660 SYCAMORE RD STE C
-----------------------------------------------------
City | MONTOURSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17754-9314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-326-8080
-----------------------------------------------------
Fax | 570-326-2733
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1660 SYCAMORE RD STE C
-----------------------------------------------------
City | MONTOURSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17754-9314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-326-8080
-----------------------------------------------------
Fax | 570-326-2733
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SAM F STEA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 570-326-8080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number | OS 003541-L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------