Basic Information
Provider Information | |||||||||
NPI: | 1114256146 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRIMARY HEALTH NETWORK | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NEW CASTLE DENTAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 63 PITT ST | ||||||||
Address2: |   | ||||||||
City: | SHARON | ||||||||
State: | PA | ||||||||
PostalCode: | 161462102 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7243423002 | ||||||||
FaxNumber: | 7243421942 | ||||||||
Practice Location | |||||||||
Address1: | 2807 WILMINGTON RD | ||||||||
Address2: |   | ||||||||
City: | NEW CASTLE | ||||||||
State: | PA | ||||||||
PostalCode: | 161051263 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7246563486 | ||||||||
FaxNumber: | 7245987337 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/22/2009 | ||||||||
LastUpdateDate: | 07/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SIZER | ||||||||
AuthorizedOfficialFirstName: | CARL | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 7243420126 | ||||||||
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 | 1007578460100 | 05 | PA |   | MEDICAID |