Provider Demographics
NPI:1871628651
Name:MEDICAL ASSOCIATES OF BOSWELL
Entity type:Organization
Organization Name:MEDICAL ASSOCIATES OF BOSWELL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:O
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-893-5568
Mailing Address - Street 1:136 S PINE AVE
Mailing Address - Street 2:BOX 340
Mailing Address - City:STOYSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15563-6002
Mailing Address - Country:US
Mailing Address - Phone:814-893-5568
Mailing Address - Fax:814-893-5989
Practice Address - Street 1:136 S PINE AVE
Practice Address - Street 2:
Practice Address - City:STOYSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15563-6002
Practice Address - Country:US
Practice Address - Phone:814-893-5568
Practice Address - Fax:814-893-5989
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDICAL ASSOCIATES OF BOSWELL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-22
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
PA261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000069206OtherHIGHMARK
PA1007698380001Medicaid
PA000322665OtherHIGHMARK
PA1007698380002Medicaid
PA1007698380001Medicaid
PA393821Medicare PIN
PA1007698380002Medicaid