Provider Demographics
NPI:1437443041
Name:WASHINGTON PHYSICIANS SERVICES ORGANIZATION
Entity Type:Organization
Organization Name:WASHINGTON PHYSICIANS SERVICES ORGANIZATION
Other - Org Name:WASHINGTON HEALTH SYSTEM - LAKESIDE PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SCANLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-229-1756
Mailing Address - Street 1:1001 WATERDAM PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:MC MURRAY
Mailing Address - State:PA
Mailing Address - Zip Code:15317-2466
Mailing Address - Country:US
Mailing Address - Phone:724-969-1001
Mailing Address - Fax:724-260-5448
Practice Address - Street 1:1001 WATERDAM PLAZA DR
Practice Address - Street 2:
Practice Address - City:MC MURRAY
Practice Address - State:PA
Practice Address - Zip Code:15317-2466
Practice Address - Country:US
Practice Address - Phone:724-229-1758
Practice Address - Fax:724-229-2429
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WASHINGTON HEALTH CARE SERVICES INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-01
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD062991L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA875375Medicare PIN