Provider Demographics
NPI:1699153247
Name:CONCORDIA PHYSICIAN PRACTICE
Entity type:Organization
Organization Name:CONCORDIA PHYSICIAN PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:E
Authorized Official - Last Name:FRNDAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-352-1571
Mailing Address - Street 1:112 MARWOOD ROAD #5000
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:PA
Mailing Address - Zip Code:16023-2245
Mailing Address - Country:US
Mailing Address - Phone:724-352-4448
Mailing Address - Fax:724-352-4412
Practice Address - Street 1:112 MARWOOD ROAD #5000
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:PA
Practice Address - Zip Code:16023-2245
Practice Address - Country:US
Practice Address - Phone:724-352-4448
Practice Address - Fax:724-352-4412
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONCORDIA LUTHERAN MINISTRIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-15
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty