Basic Information
| Provider Information | |||||||||
| NPI: | 1083601249 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NITTANY VALLEY MEDICAL ASSOCIATES P.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2134 SANDY DR STE 16 | ||||||||
| Address2: | |||||||||
| City: | STATE COLLEGE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168032292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142725805 | ||||||||
| FaxNumber: | 8142720110 | ||||||||
| Practice Location | |||||||||
| Address1: | 2134 SANDY DR STE 16 | ||||||||
| Address2: | |||||||||
| City: | STATE COLLEGE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168032292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142725805 | ||||||||
| FaxNumber: | 8142720110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 10/28/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLARKE | ||||||||
| AuthorizedOfficialFirstName: | EILEEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8143596866 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1409586 | 01 | PA | HIGHMARK BS | OTHER | 0019162000001 | 05 | PA | MEDICAID | 104H | 01 | PA | GEISINGER | OTHER | 50000799 | 01 | PA | CAPITAL BC/BS | OTHER | CJ9571 | 01 | PA | RAILROAD MEDICARE | OTHER |