Provider Demographics
NPI:1386848760
Name:ELK REGIONAL PROFESSIONAL GROUP, INC.
Entity Type:Organization
Organization Name:ELK REGIONAL PROFESSIONAL GROUP, INC.
Other - Org Name:PLATT ST. MARYS LAB
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:YOUNT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-788-8615
Mailing Address - Street 1:763 JOHNSONBURG RD
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:PA
Mailing Address - Zip Code:15857-3417
Mailing Address - Country:US
Mailing Address - Phone:814-788-8580
Mailing Address - Fax:814-788-8042
Practice Address - Street 1:121 E ARCH ST
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:PA
Practice Address - Zip Code:15857-1769
Practice Address - Country:US
Practice Address - Phone:814-834-2850
Practice Address - Fax:814-781-1580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA028362291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA065132 Q8NMedicare ID - Type UnspecifiedGROUP MEDICARE