Provider Demographics
NPI:1821195033
Name:INDIANA HEALTHCARE PHYSICIAN SERVICES, INC
Entity Type:Organization
Organization Name:INDIANA HEALTHCARE PHYSICIAN SERVICES, INC
Other - Org Name:D/B/A PUNXSUTAWNEY PHYSICIAN GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-452-4762
Mailing Address - Street 1:81 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:PUNXSUTAWNEY
Mailing Address - State:PA
Mailing Address - Zip Code:15767-2605
Mailing Address - Country:US
Mailing Address - Phone:814-938-1451
Mailing Address - Fax:814-938-1451
Practice Address - Street 1:81 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:PUNXSUTAWNEY
Practice Address - State:PA
Practice Address - Zip Code:15767-2605
Practice Address - Country:US
Practice Address - Phone:814-938-1451
Practice Address - Fax:814-938-1451
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INDIANA HEALTHCARE PHYSICIAN SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD450924204R00000X
PAMD450155207Y00000X
PAMD447392208600000X
PAMD446903208600000X
208800000X
PAMD417193208D00000X
PAMD037172L208D00000X
PASP012816363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic MedicineGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABO65OtherUPMC
PA0015479580004Medicaid
PA0015479580004Medicaid
PA0015479580004Medicaid