Provider Demographics
NPI:1003228172
Name:UPMC COMMUNITY MEDICINE INC
Entity Type:Organization
Organization Name:UPMC COMMUNITY MEDICINE INC
Other - Org Name:LAKESIDE FAMILY MEDICINE-UPMC
Other - Org Type:Other Name
Authorized Official - Title/Position:SR.DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:EHALT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-647-0943
Mailing Address - Street 1:11065 STATE HIGHWAY 18
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CONNEAUT LAKE
Mailing Address - State:PA
Mailing Address - Zip Code:16316-3569
Mailing Address - Country:US
Mailing Address - Phone:814-382-6550
Mailing Address - Fax:
Practice Address - Street 1:11065 STATE HIGHWAY 18
Practice Address - Street 2:SUITE 1
Practice Address - City:CONNEAUT LAKE
Practice Address - State:PA
Practice Address - Zip Code:16316-3569
Practice Address - Country:US
Practice Address - Phone:814-382-6550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-23
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA042490Medicare PIN