Provider Demographics
NPI:1760642896
Name:EAST LIBERTY FAMILY HEALTH CARE CENTER, INC.
Entity Type:Organization
Organization Name:EAST LIBERTY FAMILY HEALTH CARE CENTER, INC.
Other - Org Name:EAST LIBERTY FAMILY HEALTH CARE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:412-362-6353
Mailing Address - Street 1:6023 HARVARD SQ
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15206-3053
Mailing Address - Country:US
Mailing Address - Phone:412-661-2802
Mailing Address - Fax:412-661-8020
Practice Address - Street 1:6023 HARVARD SQ
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15206-3053
Practice Address - Country:US
Practice Address - Phone:412-661-2802
Practice Address - Fax:412-661-8020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-12
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007524920001Medicaid
PA391871Medicare Oscar/Certification
PA072139Medicare PIN