Provider Demographics
NPI:1114130929
Name:FAIRFIELD AVE FAMILY PRACTICE
Entity type:Organization
Organization Name:FAIRFIELD AVE FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:KOWTONIUK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:814-535-6167
Mailing Address - Street 1:226 FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15906-2310
Mailing Address - Country:US
Mailing Address - Phone:814-535-6167
Mailing Address - Fax:
Practice Address - Street 1:226 FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15906-2310
Practice Address - Country:US
Practice Address - Phone:814-535-6167
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007300380005Medicaid
PA1007300380005Medicaid