Provider Demographics
NPI:1891980355
Name:LIFE-NORTHWESTERN PENNSYLVANIA
Entity Type:Organization
Organization Name:LIFE-NORTHWESTERN PENNSYLVANIA
Other - Org Name:LUTHERAN HOME FOR THE AGED
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:GUSEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-456-5433
Mailing Address - Street 1:100 STATE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1454
Mailing Address - Country:US
Mailing Address - Phone:814-456-5433
Mailing Address - Fax:814-454-2500
Practice Address - Street 1:149 W 22ND ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16502-2804
Practice Address - Country:US
Practice Address - Phone:814-452-3271
Practice Address - Fax:814-456-9232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007767250005Medicaid