Provider Demographics
NPI:1356473094
Name:CONNEAUT VALLEY HEALTH CENTER PODIATRY
Entity Type:Organization
Organization Name:CONNEAUT VALLEY HEALTH CENTER PODIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:DOWNING
Authorized Official - Suffix:
Authorized Official - Credentials:FACHE, CMPE
Authorized Official - Phone:814-373-2449
Mailing Address - Street 1:1009 WATER ST
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-3465
Mailing Address - Country:US
Mailing Address - Phone:814-373-2449
Mailing Address - Fax:814-373-3050
Practice Address - Street 1:906 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CONNEAUTVILLE
Practice Address - State:PA
Practice Address - Zip Code:16406-7138
Practice Address - Country:US
Practice Address - Phone:814-373-2276
Practice Address - Fax:814-587-2918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC004174R213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007230030001Medicaid
PAU63299Medicare UPIN
PA0007230030001Medicaid