Provider Demographics
NPI:1477784106
Name:CLEAR MED PROVIDER CORPORATION
Entity Type:Organization
Organization Name:CLEAR MED PROVIDER CORPORATION
Other - Org Name:CLEAR MED PODIATRY
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 1:820 TURNPIKE AVE
Practice Address - Street 2:
Practice Address - City:CLEARFIELD
Practice Address - State:PA
Practice Address - Zip Code:16830-1233
Practice Address - Country:US
Practice Address - Phone:814-765-2006
Practice Address - Fax:814-765-8807
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLEARFIELD HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-29
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC005951213ES0103X
261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatricGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2125484OtherHIGHMARK ASSIGNMENT ACCOUNT
PA2125484OtherHIGHMARK ASSIGNMENT ACCOUNT