Provider Demographics
NPI:1720056138
Name:JEFFERSON REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:JEFFERSON REGIONAL MEDICAL CENTER
Other - Org Name:JEFFERSON HOSPITAL COUNSELING SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP FINANCE AHN
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:FRIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-330-2472
Mailing Address - Street 1:810 CLAIRTON BLVD STE 500600
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15236-5505
Mailing Address - Country:US
Mailing Address - Phone:412-650-1100
Mailing Address - Fax:412-650-1101
Practice Address - Street 1:810 CLAIRTON BLVD STE 500600
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15236-5505
Practice Address - Country:US
Practice Address - Phone:412-650-1100
Practice Address - Fax:412-650-1101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-10
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2084P0800X
PA273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes273R00000XHospital UnitsPsychiatric Unit
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0927OtherHIGHMARK BCBS
PA1007443470035Medicaid
PA39S265Medicare Oscar/Certification