MEDICARE: COUNTRYSIDE CONVALESCENT HOME LIMITED PARTNERSHIP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1121	OTHER		HIGHMARK BC
2	1501006	OTHER	PA	GATEWAY HP
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	263249	OTHER	PA	HEALTH AMERICA
5	305354	OTHER		UPMC

General Provider Information

NPI Number	:	1376537431
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTRYSIDE CONVALESCENT HOME LIMITED PARTNERSHIP

Provider Business Mailing Address
First Line	:	8221 LAMOR RD
Second Line	:
City	:	MERCER
State	:	PA
Zip	:	16137-3163
Country	:	US
Telephone Number	:	724-431-0770
Fax Number	:	724-431-0764

Provider Business Practice Location Address
First Line	:	8221 LAMOR RD
Second Line	:
City	:	MERCER
State	:	PA
Zip	:	16137-3163
Country	:	US
Telephone Number	:	724-431-0770
Fax Number	:	724-431-0764

Authorized Official
Title or Position	:	CEO
Name	:	STEVEN D TACK
Credential	:	NHA
Telephone Number	:	724-431-0770

Provider Enumeration Date	:	09/06/2005
Last Update Date	:	08/14/2014

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Directions to “COUNTRYSIDE CONVALESCENT HOME LIMITED PARTNERSHIP ” Practice Location

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