Provider Demographics
NPI:1952329914
Name:FAMILY PRACTICE MEDICAL ASSOCIATE SOUTH INC.
Entity Type:Organization
Organization Name:FAMILY PRACTICE MEDICAL ASSOCIATE SOUTH INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:NOEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-330-5861
Mailing Address - Street 1:4 ALLEGHENY CTR FL 7
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15212-5255
Mailing Address - Country:US
Mailing Address - Phone:412-330-5861
Mailing Address - Fax:412-330-5544
Practice Address - Street 1:1200 BROOKS LN
Practice Address - Street 2:SUITE 290
Practice Address - City:JEFFERSON HILLS
Practice Address - State:PA
Practice Address - Zip Code:15025-3765
Practice Address - Country:US
Practice Address - Phone:412-729-1500
Practice Address - Fax:412-384-2462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014710810002Medicaid
PA0014710810003Medicaid
PA0014710810006Medicaid
PA606938OtherHIGHMARK BC/BS
PA0014710810006Medicaid