MEDICARE: CENTERVILLE CLINICS INC

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	207Q00000X	Family Medicine Physician
2	261QF0400X	Federally Qualified Health Center (FQHC)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598314908
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTERVILLE CLINICS INC

Provider Business Mailing Address
First Line	:	CENTERVILLE CLINICS INC
Second Line	:	1070 OLD NATIONAL PIKE ROAD
City	:	FREDERICKTOWN
State	:	PA
Zip	:	15333-2114
Country	:	US
Telephone Number	:	724-632-6801
Fax Number	:	724-632-6312

Provider Business Practice Location Address
First Line	:	CENTERVILLE CLINICS - CITY MISSION SITE
Second Line	:	84 W WHEELING STREET
City	:	WASHINGTON
State	:	PA
Zip	:	15301-6918
Country	:	US
Telephone Number	:	724-222-8530
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. BARRY R NICCOLAI
Credential	:
Telephone Number	:	724-632-6801

Provider Enumeration Date	:	09/09/2019
Last Update Date	:	09/09/2019

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Directions to “CENTERVILLE CLINICS INC ” Practice Location

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