Provider Demographics
NPI:1104881648
Name:GATEWAY AREA MEDICAL PCP
Entity type:Organization
Organization Name:GATEWAY AREA MEDICAL PCP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING DEPT
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:NOWAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-371-1771
Mailing Address - Street 1:635C MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-2377
Mailing Address - Country:US
Mailing Address - Phone:814-371-1771
Mailing Address - Fax:814-371-4417
Practice Address - Street 1:635C MAPLE AVE
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-2377
Practice Address - Country:US
Practice Address - Phone:814-371-1771
Practice Address - Fax:814-371-4417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010511850004Medicaid