Provider Demographics
NPI:1386877801
Name:SPECIALTY GROUP PRACTICE 1, INC.
Entity type:Organization
Organization Name:SPECIALTY GROUP PRACTICE 1, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHET
Authorized Official - Middle Name:
Authorized Official - Last Name:PHITAYAKORN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:412-469-7030
Mailing Address - Street 1:575 COAL VALLEY RD
Mailing Address - Street 2:SUITE 365
Mailing Address - City:CLAIRTON
Mailing Address - State:PA
Mailing Address - Zip Code:15025-3730
Mailing Address - Country:US
Mailing Address - Phone:412-469-7030
Mailing Address - Fax:
Practice Address - Street 1:575 COAL VALLEY RD
Practice Address - Street 2:SUITE 365
Practice Address - City:CLAIRTON
Practice Address - State:PA
Practice Address - Zip Code:15025-3730
Practice Address - Country:US
Practice Address - Phone:412-469-7030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JEFFERSON REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-01
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD031414L208G00000X
PAMD038772E208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty