Provider Demographics
NPI:1790951655
Name:CENTERVILLE CLINICS, INC CONNELLSVILLE MH
Entity Type:Organization
Organization Name:CENTERVILLE CLINICS, INC CONNELLSVILLE MH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR FINANCE AND PERSONNEL
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATTY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-632-6801
Mailing Address - Street 1:1070 OLD NATIONAL PIKE
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15333-2114
Mailing Address - Country:US
Mailing Address - Phone:724-632-6801
Mailing Address - Fax:724-632-6312
Practice Address - Street 1:208 S ARCH ST
Practice Address - Street 2:
Practice Address - City:CONNELLSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15425-3519
Practice Address - Country:US
Practice Address - Phone:724-626-2630
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
PA391911261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA391911OtherNATIONAL GOVERNMENT SERVICES
PA1007288440037Medicaid
PA328834A776089OtherVALUE BEHAVIORAL HEALTH