Provider Demographics
NPI:1912924804
Name:EXCELA HEALTH PHYSICIAN PRACTICES
Entity Type:Organization
Organization Name:EXCELA HEALTH PHYSICIAN PRACTICES
Other - Org Name:EXCELA HEALTH CONNELLSVILLE FAMILY PRACTICE-R. CONN, MD
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:SPHON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-830-8500
Mailing Address - Street 1:2616 MEMORIAL BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:CONNELLSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15425-1418
Mailing Address - Country:US
Mailing Address - Phone:724-628-9350
Mailing Address - Fax:724-628-9353
Practice Address - Street 1:2616 MEMORIAL BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:CONNELLSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15425-1418
Practice Address - Country:US
Practice Address - Phone:724-628-9350
Practice Address - Fax:724-628-9353
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EXCELA HEALTH PHYSICIAN PRACTICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-16
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD427026207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015621860064Medicaid
PA0015621860064Medicaid