Provider Demographics
NPI:1225241805
Name:CLARION UNIVERSITY OF PENNSYLVANIA
Entity Type:Organization
Organization Name:CLARION UNIVERSITY OF PENNSYLVANIA
Other - Org Name:NORTHWEST PA RURAL AIDS ALLIANCE
Other - Org Type:Other Name
Authorized Official - Title/Position:FISCAL ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:KUNDICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-297-8220
Mailing Address - Street 1:15870 ROUTE 322
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CLARION
Mailing Address - State:PA
Mailing Address - Zip Code:16214-6338
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15870 ROUTE 322
Practice Address - Street 2:SUITE 2
Practice Address - City:CLARION
Practice Address - State:PA
Practice Address - Zip Code:16214-6338
Practice Address - Country:US
Practice Address - Phone:814-764-6066
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RI0200X
PA251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
No251B00000XAgenciesCase ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1002302280003Medicaid