Provider Demographics
NPI:1679947378
Name:GEORGE CARLSON
Entity type:Organization
Organization Name:GEORGE CARLSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:LSW
Authorized Official - Phone:814-952-7103
Mailing Address - Street 1:6068 ROUTE 119
Mailing Address - Street 2:
Mailing Address - City:PUNXSUTAWNEY
Mailing Address - State:PA
Mailing Address - Zip Code:15767-4019
Mailing Address - Country:US
Mailing Address - Phone:814-952-7103
Mailing Address - Fax:
Practice Address - Street 1:6068 ROUTE 119
Practice Address - Street 2:
Practice Address - City:PUNXSUTAWNEY
Practice Address - State:PA
Practice Address - Zip Code:15767
Practice Address - Country:US
Practice Address - Phone:814-952-7103
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-18
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW132824302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2254Medicaid