Provider Demographics
NPI:1588761845
Name:PENNSYLVANIA DEPARTMENT OF MILITARY AND VETERANS' AFFAIRS
Entity type:Organization
Organization Name:PENNSYLVANIA DEPARTMENT OF MILITARY AND VETERANS' AFFAIRS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FISCAL SERVICES ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:REED
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:814-242-7789
Mailing Address - Street 1:PO BOX 6239
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16512-6239
Mailing Address - Country:US
Mailing Address - Phone:814-871-4531
Mailing Address - Fax:814-871-4617
Practice Address - Street 1:560 E 3RD ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-1753
Practice Address - Country:US
Practice Address - Phone:814-871-4531
Practice Address - Fax:814-871-4617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1982022865M2000X
PA448290310400000X
313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No2865M2000XHospitalsMilitary HospitalMilitary General Acute Care Hospital
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA524164Medicare ID - Type UnspecifiedMEDICARE