Basic Information
| Provider Information | |||||||||
| NPI: | 1720205065 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PULMONARY REHABILITATION ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 925 TRAILWOOD DR | ||||||||
| Address2: | |||||||||
| City: | YOUNGSTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445125008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307587575 | ||||||||
| FaxNumber: | 3307581833 | ||||||||
| Practice Location | |||||||||
| Address1: | 925 TRAILWOOD DR | ||||||||
| Address2: | |||||||||
| City: | YOUNGSTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445125008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307587575 | ||||||||
| FaxNumber: | 3307581833 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2007 | ||||||||
| LastUpdateDate: | 01/24/2012 | ||||||||
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| AuthorizedOfficialLastName: | SHUNTICH | ||||||||
| AuthorizedOfficialFirstName: | MARIJO | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3307587575 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 607700 | 01 | OH | BLACK LUNG | OTHER | 0763973 | 05 | OH | MEDICAID |