Provider Demographics
NPI:1558615484
Name:MASONIC VILLAGES OF THE GRAND LODGE OF PENNSYLVANIA
Entity Type:Organization
Organization Name:MASONIC VILLAGES OF THE GRAND LODGE OF PENNSYLVANIA
Other - Org Name:MASONIC VILLAGE AT SEWICKLEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:FORMICA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-367-1121
Mailing Address - Street 1:1000 MASONIC DR
Mailing Address - Street 2:
Mailing Address - City:SEWICKLEY
Mailing Address - State:PA
Mailing Address - Zip Code:15143-2328
Mailing Address - Country:US
Mailing Address - Phone:412-741-1400
Mailing Address - Fax:412-741-0747
Practice Address - Street 1:1000 MASONIC DR
Practice Address - Street 2:
Practice Address - City:SEWICKLEY
Practice Address - State:PA
Practice Address - Zip Code:15143-2328
Practice Address - Country:US
Practice Address - Phone:412-741-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-30
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA221402314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0579OtherSECURITY BLUE
PA395638Medicare PIN