Provider Demographics
NPI:1952421968
Name:WHITE DEER RUN, INC
Entity type:Organization
Organization Name:WHITE DEER RUN, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:CALLAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-873-2131
Mailing Address - Street 1:1921 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-4936
Mailing Address - Country:US
Mailing Address - Phone:814-452-2291
Mailing Address - Fax:
Practice Address - Street 1:1921 W 8TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-4936
Practice Address - Country:US
Practice Address - Phone:814-452-2291
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-31
Last Update Date:2015-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA00257052261QR0405X, 251S00000X
PA257052261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007567870028Medicaid
PA1007567870089Medicaid
PA1007567870072Medicaid