Provider Demographics
NPI:1669709655
Name:EAST LIBERTY FAMILY HEALTH CARE CENTER, INC.
Entity type:Organization
Organization Name:EAST LIBERTY FAMILY HEALTH CARE CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:412-362-6353
Mailing Address - Street 1:6023 HARVARD SQ
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15206-3053
Mailing Address - Country:US
Mailing Address - Phone:412-361-8284
Mailing Address - Fax:412-361-8268
Practice Address - Street 1:807 WALLACE AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15221-2312
Practice Address - Country:US
Practice Address - Phone:412-345-7730
Practice Address - Fax:412-242-0602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-11
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007524920015Medicaid