Provider Demographics
NPI:1255387015
Name:FAMILY MEDICINE OF WARREN, PA,PC
Entity type:Organization
Organization Name:FAMILY MEDICINE OF WARREN, PA,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAT
Authorized Official - Middle Name:A
Authorized Official - Last Name:BENGSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-726-3310
Mailing Address - Street 1:143 PLEASANT DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365-3371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:143 PLEASANT DR
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-3371
Practice Address - Country:US
Practice Address - Phone:814-726-3310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001181789Medicaid
PA001181789Medicaid