Provider Demographics
NPI:1568666949
Name:ELK REGIONAL PROFESSIONAL GROUP, INC.
Entity Type:Organization
Organization Name:ELK REGIONAL PROFESSIONAL GROUP, INC.
Other - Org Name:ECMA - RIDGWAY LAB
Other - Org Type:Other Name
Authorized Official - Title/Position: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:814-788-8580
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 1:123 SOUTH ST
Practice Address - Street 2:
Practice Address - City:RIDGWAY
Practice Address - State:PA
Practice Address - Zip Code:15853-2008
Practice Address - Country:US
Practice Address - Phone:814-781-7531
Practice Address - Fax:814-781-7494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA028359291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA065273 Q83Medicare ID - Type UnspecifiedGROUP MEDICARE