Basic Information
| Provider Information | |||||||||
| NPI: | 1134168461 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHADYSIDE NURSING AND REHABILITATION CENTER-PITTSBURGH PA LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROMEDICA SKILLED NURSING AND REHABILITATION (SHADYSIDE) | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 N SUMMIT ST | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436041531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192525500 | ||||||||
| FaxNumber: | 8773859446 | ||||||||
| Practice Location | |||||||||
| Address1: | 5609 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152322601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4123623500 | ||||||||
| FaxNumber: | 4123621951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 01/28/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | MARTIN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4192525743 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 090302 | PA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1020584140001 | 05 | PA | MEDICAID |