Provider Demographics
NPI:1164064002
Name:CENTERVILLE CLINICS INC
Entity Type:Organization
Organization Name:CENTERVILLE CLINICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:NICCOLAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-632-6801
Mailing Address - Street 1:CENTERVILLE CLINICS INC
Mailing Address - Street 2:1070 OLD NATIONAL PIKE ROAD
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15333-2114
Mailing Address - Country:US
Mailing Address - Phone:724-632-6801
Mailing Address - Fax:724-632-6312
Practice Address - Street 1:CENTERVILLE CLINICS-DONORA FAMILY MEDICINE
Practice Address - Street 2:718 MCKEAN AVENUE
Practice Address - City:DONORA
Practice Address - State:PA
Practice Address - Zip Code:15033-1061
Practice Address - Country:US
Practice Address - Phone:724-379-4401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007288440027Medicaid