Provider Demographics
NPI:1336136720
Name:ELK REGIONAL PROFESSIONAL GROUP, INC
Entity Type:Organization
Organization Name:ELK REGIONAL PROFESSIONAL GROUP, INC
Other - Org Name:ERPG KEYSTONE MEDICAL ASSOCIATES
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT, ERPG
Authorized Official - Prefix:
Authorized Official - First Name:RITA
Authorized Official - Middle Name:V
Authorized Official - Last Name:OLSZEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-788-8580
Mailing Address - Street 1:136 STATE ST
Mailing Address - Street 2:
Mailing Address - City:ST MARYS
Mailing Address - State:PA
Mailing Address - Zip Code:15857-1626
Mailing Address - Country:US
Mailing Address - Phone:814-781-6758
Mailing Address - Fax:814-834-1038
Practice Address - Street 1:136 STATE ST
Practice Address - Street 2:
Practice Address - City:ST MARYS
Practice Address - State:PA
Practice Address - Zip Code:15857-1626
Practice Address - Country:US
Practice Address - Phone:814-781-6758
Practice Address - Fax:814-834-1038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018592850010Medicaid
PA1418283OtherHIGHMARK ASSIGNMENT
PA1418283OtherHIGHMARK ASSIGNMENT