Provider Demographics
NPI:1962469486
Name:PORT ALLEGANY AREA FAMILY PRACTICE PC
Entity Type:Organization
Organization Name:PORT ALLEGANY AREA FAMILY PRACTICE PC
Other - Org Name:UPPER ALLEGHENY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:H
Authorized Official - Last Name:SHELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-642-9531
Mailing Address - Street 1:1 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:PORT ALLEGANY
Mailing Address - State:PA
Mailing Address - Zip Code:16743-1332
Mailing Address - Country:US
Mailing Address - Phone:814-642-9531
Mailing Address - Fax:814-642-2020
Practice Address - Street 1:1 WILLOW ST
Practice Address - Street 2:
Practice Address - City:PORT ALLEGANY
Practice Address - State:PA
Practice Address - Zip Code:16743-1332
Practice Address - Country:US
Practice Address - Phone:814-642-9531
Practice Address - Fax:814-642-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD029656E207Q00000X
261QR1300X
PAMA053689363AM0700X
PASP008214363LF0000X
PASP009929363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CF9006OtherRAILROAD MEDICARE
PA0014032880001Medicaid
PA861827OtherHIGHMARK BLUE SHIELD
PA861827OtherHIGHMARK BLUE SHIELD
CF9006OtherRAILROAD MEDICARE
PA0014032880001Medicaid