Basic Information
| Provider Information | |||||||||
| NPI: | 1063641470 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIMARY HEALTH NETWORK | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ALTOONA BEHAVIORAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 63 PITT ST | ||||||||
| Address2: | |||||||||
| City: | SHARON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 161462102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7243423002 | ||||||||
| FaxNumber: | 7243421942 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 HOWARD AVE | ||||||||
| Address2: | |||||||||
| City: | ALTOONA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 166014804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8149425000 | ||||||||
| FaxNumber: | 8149429500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2009 | ||||||||
| LastUpdateDate: | 07/18/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SIZER | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7243420216 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | 07/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | PA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1007578460095 | 05 | PA | MEDICAID |