Provider Demographics
NPI:1205099421
Name:KATHLEEN WIECZOREK
Entity type:Organization
Organization Name:KATHLEEN WIECZOREK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:BARB
Authorized Official - Middle Name:
Authorized Official - Last Name:BECKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-386-9300
Mailing Address - Street 1:5050 W RIDGE RD FL 2
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-1216
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5050 W RIDGE RD FL 2
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-1216
Practice Address - Country:US
Practice Address - Phone:814-836-3900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006523L291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016175890009Medicaid
PA0016175890009Medicaid