Provider Demographics
NPI:1962748095
Name:UPMC CHAUTAUQUA AT WCA
Entity type:Organization
Organization Name:UPMC CHAUTAUQUA AT WCA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:NELSON
Authorized Official - Last Name:DINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-877-3739
Mailing Address - Street 1:207 FOOTE AVE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-7077
Mailing Address - Country:US
Mailing Address - Phone:716-487-0141
Mailing Address - Fax:716-487-2488
Practice Address - Street 1:207 FOOTE AVE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-7077
Practice Address - Country:US
Practice Address - Phone:716-487-0141
Practice Address - Fax:716-487-2488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-18
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0602001H207VG0400X, 208600000X
207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04104376Medicaid