Provider Demographics
NPI:1285797654
Name:PLASTIC SURGICAL ASSOCIATES OF JOHNSTOWN INC
Entity type:Organization
Organization Name:PLASTIC SURGICAL ASSOCIATES OF JOHNSTOWN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:NEVARRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-536-9000
Mailing Address - Street 1:415 NAPOLEON PL
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15901-2504
Mailing Address - Country:US
Mailing Address - Phone:814-536-9000
Mailing Address - Fax:814-536-8999
Practice Address - Street 1:415 NAPOLEON PL
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15901-2504
Practice Address - Country:US
Practice Address - Phone:814-536-9000
Practice Address - Fax:814-536-8999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2086S0122X
PA032123291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA032123OtherLABORATORY STATE LICENSE NUMBER
PA0006508380002Medicaid
PA012931OtherHIGHMARK GROUP NUMBER
PA39D2029791OtherCLIA
PA39D2029791OtherCLIA