Provider Demographics
NPI:1356509046
Name:CLEAR MED PROVIDER CORPORATION
Entity Type:Organization
Organization Name:CLEAR MED PROVIDER CORPORATION
Other - Org Name:CLEAR MED OB/GYN
Other - Org Type:Other Name
Authorized Official - Title/Position:CLEAR MED ADMINISTRATOR
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:814-768-2356
Mailing Address - Street 1:809 TURNPIKE AVE
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:16830-1232
Mailing Address - Country:US
Mailing Address - Phone:814-768-2356
Mailing Address - Fax:814-768-2134
Practice Address - Street 1:807 TURNPIKE AVE
Practice Address - Street 2:SUITE 260
Practice Address - City:CLEARFIELD
Practice Address - State:PA
Practice Address - Zip Code:16830-1239
Practice Address - Country:US
Practice Address - Phone:814-765-4151
Practice Address - Fax:814-768-7319
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLEARFIELD HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-29
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD432679207V00000X
261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2158606OtherHIGHMARK BCBS ASSIGNMENT ACCOUNT
PA2158606OtherHIGHMARK BCBS ASSIGNMENT ACCOUNT