Provider Demographics
NPI:1295005361
Name:FAMILY HEALTH CARE CENTER OF PUNXSUTAWNEY, INC.
Entity Type:Organization
Organization Name:FAMILY HEALTH CARE CENTER OF PUNXSUTAWNEY, INC.
Other - Org Name:FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:STATES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-938-3550
Mailing Address - Street 1:83 HILLCREST DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PUNXSUTAWNEY
Mailing Address - State:PA
Mailing Address - Zip Code:15767-2605
Mailing Address - Country:US
Mailing Address - Phone:814-938-3550
Mailing Address - Fax:814-938-3679
Practice Address - Street 1:83 HILLCREST DR
Practice Address - Street 2:SUITE 200
Practice Address - City:PUNXSUTAWNEY
Practice Address - State:PA
Practice Address - Zip Code:15767-2605
Practice Address - Country:US
Practice Address - Phone:814-938-3550
Practice Address - Fax:814-938-3679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-06
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA393918261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1019257860003Medicaid
393918OtherRHC CCN