Basic Information
| Provider Information | |||||||||
| NPI: | 1578695904 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIMARY HEALTH NETWORK | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | THE CENTER FOR HEALTH AND WELL BEING | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 100 SHENANGO AVE | ||||||||
| Address2: | |||||||||
| City: | SHARON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 161461503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7247048886 | ||||||||
| FaxNumber: | 7243421942 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 SHARON NEW CASTLE RD | ||||||||
| Address2: | |||||||||
| City: | FARRELL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 161211576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249818070 | ||||||||
| FaxNumber: | 7249817025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 04/23/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BURICH | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ACTING CEO | ||||||||
| AuthorizedOfficialTelephone: | 7243423002 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1007578460075 | 05 | PA | MEDICAID | 2590478 | 05 | OH | MEDICAID |