Provider Demographics
NPI:1073573010
Name:NULTON DIAGNOSTIC & TREATMENT CENTER, PC
Entity Type:Organization
Organization Name:NULTON DIAGNOSTIC & TREATMENT CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIESHEIMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-262-0025
Mailing Address - Street 1:214 COLLEGE PARK PLAZA
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15904-2833
Mailing Address - Country:US
Mailing Address - Phone:814-262-0025
Mailing Address - Fax:814-266-8745
Practice Address - Street 1:214 COLLEGE PARK PLZ
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904-2833
Practice Address - Country:US
Practice Address - Phone:814-262-0025
Practice Address - Fax:814-266-8745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-24
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 2084P0005X, 2084P0800X
PA314080251S00000X
PA117055251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0005XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurodevelopmental DisabilitiesGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007324900011Medicaid
PA1007324900011Medicaid