Basic Information
| Provider Information | |||||||||
| NPI: | 1275502791 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PULMONARY & CRITICAL CARE MEDICINE ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 N 12TH ST | ||||||||
| Address2: | |||||||||
| City: | LEMOYNE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170431428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172342561 | ||||||||
| FaxNumber: | 7172361121 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 N 12TH ST | ||||||||
| Address2: | |||||||||
| City: | LEMOYNE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170431428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172342561 | ||||||||
| FaxNumber: | 7172361121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | ALEXANDER | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7172342561 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MBA, MFS, FACHE | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | PA | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 174400000X | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0022317 | 01 | PA | BLUE SHIELD | OTHER |