Provider Demographics
NPI:1598728024
Name:MEADVILLE OBSTETRICS AND GYNECOLOGY ASSOCIATES
Entity Type:Organization
Organization Name:MEADVILLE OBSTETRICS AND GYNECOLOGY ASSOCIATES
Other - Org Name:MEADVILLE OB/GYN ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SIDNEY
Authorized Official - Middle Name:KWOKYIN
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-333-5888
Mailing Address - Street 1:765 LIBERTY STREET
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335
Mailing Address - Country:US
Mailing Address - Phone:814-333-5888
Mailing Address - Fax:814-333-5026
Practice Address - Street 1:765 LIBERTY STREET
Practice Address - Street 2:SUITE 202
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335
Practice Address - Country:US
Practice Address - Phone:814-333-5888
Practice Address - Fax:814-333-5026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-07
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017096170002Medicaid
433802OtherBLUE SHIELD
021123Medicare ID - Type Unspecified