Provider Demographics
NPI:1134303233
Name:CCMH SURGICAL SPECIALISTS
Entity Type:Organization
Organization Name:CCMH SURGICAL SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ED
Authorized Official - Middle Name:
Authorized Official - Last Name:PITCHFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-274-5216
Mailing Address - Street 1:1001 EAST SECOND STREET
Mailing Address - Street 2:
Mailing Address - City:COUDERSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:16915
Mailing Address - Country:US
Mailing Address - Phone:814-274-9300
Mailing Address - Fax:
Practice Address - Street 1:1001 EAST SECOND STREET
Practice Address - Street 2:
Practice Address - City:COUDERSPORT
Practice Address - State:PA
Practice Address - Zip Code:16915
Practice Address - Country:US
Practice Address - Phone:814-274-9300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHARLES COLE MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1867505OtherBLUE SHIELD PROVIDER #