Provider Demographics
NPI:1437277373
Name:PRIMARY CARE CENTER OF MT MORRIS
Entity type:Organization
Organization Name:PRIMARY CARE CENTER OF MT MORRIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MTJOY
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:724-943-3308
Mailing Address - Street 1:104 FRONT STREET
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MOUNT MORRIS
Mailing Address - State:PA
Mailing Address - Zip Code:15349-0495
Mailing Address - Country:US
Mailing Address - Phone:724-324-9001
Mailing Address - Fax:724-324-9005
Practice Address - Street 1:104 FRONT STREET
Practice Address - Street 2:SUITE 102
Practice Address - City:MOUNT MORRIS
Practice Address - State:PA
Practice Address - Zip Code:15349-0495
Practice Address - Country:US
Practice Address - Phone:724-324-9001
Practice Address - Fax:724-324-9005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA080019751680001Medicaid
PA391934Medicare ID - Type UnspecifiedFQHC LOOK-A-LIKE
391934Medicare PIN