Provider Demographics
NPI:1902826290
Name:JEANNETTE PRIMARY CARE
Entity Type:Organization
Organization Name:JEANNETTE PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:A
Authorized Official - Last Name:IEZZU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-527-9525
Mailing Address - Street 1:600 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:JEANNETTE
Mailing Address - State:PA
Mailing Address - Zip Code:15644-2505
Mailing Address - Country:US
Mailing Address - Phone:724-527-9525
Mailing Address - Fax:724-527-9683
Practice Address - Street 1:3000 PENNY LN
Practice Address - Street 2:
Practice Address - City:JEANNETTE
Practice Address - State:PA
Practice Address - Zip Code:15644-4306
Practice Address - Country:US
Practice Address - Phone:724-744-6167
Practice Address - Fax:724-527-9683
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JEANNETTE PRIMARY CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-20
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA=========OtherTAX ID
PA906110Medicare PIN