Provider Demographics
NPI:1396822425
Name:CONEMAUGH VALLEY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:CONEMAUGH VALLEY MEMORIAL HOSPITAL
Other - Org Name:EPSDT
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR PFS
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:DZIAGWA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-410-8296
Mailing Address - Street 1:1086 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905
Mailing Address - Country:US
Mailing Address - Phone:814-410-8296
Mailing Address - Fax:814-410-8597
Practice Address - Street 1:1086 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-4305
Practice Address - Country:US
Practice Address - Phone:814-534-1821
Practice Address - Fax:814-534-1743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1004907OtherGATEWAY EPSDT
PA1007568490053Medicaid