Basic Information
| Provider Information | |||||||||
| NPI: | 1578882924 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTEGRATED WOUND SPECIALISTS OF PENNSYLVANIA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5220 BELFORT RD STE 130 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322566018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044463451 | ||||||||
| FaxNumber: | 9044463032 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 S CENTER AVE | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | PA | ||||||||
| PostalCode: | 155012033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144438225 | ||||||||
| FaxNumber: | 8144438236 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2010 | ||||||||
| LastUpdateDate: | 03/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | BASSIN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8556895105 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DIVERSIFIED CLINICAL SERVICES, LLC | ||||||||
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| NPICertificationDate: | 03/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 2083P0011X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Undersea and Hyperbaric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1025515640-001 | 05 | PA | MEDICAID |