Provider Demographics
NPI:1063514453
Name:BROAD TOP AREA MEDICAL CENTER INC
Entity type:Organization
Organization Name:BROAD TOP AREA MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-635-2916
Mailing Address - Street 1:4133 MEDICAL CENTER DRIVE, BOX 127
Mailing Address - Street 2:
Mailing Address - City:BROAD TOP
Mailing Address - State:PA
Mailing Address - Zip Code:16621-0127
Mailing Address - Country:US
Mailing Address - Phone:814-635-2916
Mailing Address - Fax:814-635-2918
Practice Address - Street 1:4133 MEDICAL CENTER DRIVE, BOX 127
Practice Address - Street 2:
Practice Address - City:BROAD TOP
Practice Address - State:PA
Practice Address - Zip Code:16621-0127
Practice Address - Country:US
Practice Address - Phone:814-635-2916
Practice Address - Fax:814-635-2918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007496930006Medicaid
PA1007496930006Medicaid