Provider Demographics
NPI:1609390483
Name:GROVE CITY MEDICAL CENTER
Entity Type:Organization
Organization Name:GROVE CITY MEDICAL CENTER
Other - Org Name:GCMC PAIN CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:724-450-7197
Mailing Address - Street 1:631 N. BROAD STREET EXT.
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16127-4603
Mailing Address - Country:US
Mailing Address - Phone:724-450-7000
Mailing Address - Fax:724-450-7013
Practice Address - Street 1:631 N BROAD STREET EXT
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:PA
Practice Address - Zip Code:16127-4603
Practice Address - Country:US
Practice Address - Phone:724-450-7000
Practice Address - Fax:724-450-7013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-02
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS005324L207LP2900X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010895580018Medicaid
401500OtherISSUER