NPIMap

Organization Active NPI

Olean General Hospital

  • Family Medicine Physician
  • Bradford, PA
National Provider Identifier
1336411099
Registry record updated Oct 10, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
OLEAN GENERAL HOSPITAL
Practice address
116 Interstate Pkwy Ste 41
Bradford, PA 16701-1036
Phone
(814) 363-9484
Fax
(814) 362-3854
NPI assigned
Jan 27, 2012
Last updated
Oct 10, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 10, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jill M Owens, MD
Title
Ceo
Phone
(716) 373-2600

Specialties & licenses 5

Specialty (taxonomy)CodeLicenseStatePrimary
Family Nurse Practitioner 363LF0000X
Family Medicine Physician 207Q00000X PA Primary
Internal Medicine Physician 207R00000X
Pediatrics Physician 208000000X PA
Pediatrics Physician 208000000X

Addresses

Primary practice location

116 Interstate Pkwy Ste 41
Bradford, PA 16701-1036

Mailing address

908 Niagara Falls Blvd Ste 208
North Tonawanda, NY 14120-2019
Phone (716) 799-1462

Other identifiers 2

IdentifierTypeStateIssuer
1007755030029MedicaidPA
03927699MedicaidNY

Other names 1

  • Foothills Medical Group at BRMC RHC Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20180116002380 PA Part A Provider - Rural Health Clinic 9133111784 Practice locations: Bradford, PA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1336411099. Details of each certification follow.

Rural health clinic certification: CCN 393422

Legal name
OLEAN GENERAL HOSPITAL
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Nov 9, 2012
Last certification
Oct 2, 2024
Ownership / control type
2B
Most recent change of ownership
Jan 12, 2018 (1 total)
Organization structure
CorporationNon-profit
Incorporated
Jul 13, 1898 in NY
Enrollment address
116 Interstate Pkwy
Ste 41
Bradford, PA 16701-1036
Related CCNs
330103

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 10

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Physician Staffing Inc17 organizations share this tax ID, including this one

Other organizations with this tax ID 16

Organizations that report the same tax identification number in the National Provider Directory.

View all 16

Ownership & related parties

All disclosed owners & managing parties 17

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
David Prince Individual Corporate DirectorBoard Member Sep 1, 2009
Lisa Fiorentino Individual Corporate DirectorBoard Member Jan 1, 2017
Julie Marasco Individual Corporate DirectorBoard Member Jan 1, 2017
David Ferguson Individual Corporate Director Jan 1, 2022
Upper Allegheny Health System Organization, Olean, NY Non-profit Operational/Managerial Control Jan 19, 2018 100%
Melissa Scholl Individual Corporate DirectorBoard Member Jan 1, 2017
Daniel Derose Individual Corporate Director Jan 1, 2022
Douglas Pisano Individual Corporate Director Jan 1, 2022
Anil Pradhan Individual Corporate Director Jan 1, 2022
Cheryl a Klass Individual Corporate OfficerInterim Ceo Sep 4, 2024
Katie Jean Kaus O'Connell Individual Corporate OfficerVP Revenue Cycle Jun 1, 2022
Operational/Managerial Control Jun 1, 2022
Jeffrey C Belt Individual Corporate DirectorChairman Jan 1, 2017
Muhammed Javed Individual Corporate DirectorVP of Board Nov 5, 2009
Jeannine Schoenecker Individual Corporate DirectorBoard Member Jan 1, 2017
Gilbert Witte Individual Corporate Director Jan 1, 2022
Paul Ridley Individual Corporate Director Jan 1, 2022
Marc Boutillette Individual Corporate Director Jan 1, 2022

Owners & managing parties with NPI records 3

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 4

Facilities that share an organizational owner with 5% or greater ownership or operational control.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1327622400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1696896000000",
    "number": "1336411099",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "908 NIAGARA FALLS BLVD STE 208",
            "city": "NORTH TONAWANDA",
            "state": "NY",
            "postal_code": "141202019",
            "telephone_number": "716-799-1462",
            "fax_number": "833-953-2016"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "116 INTERSTATE PKWY STE 41",
            "city": "BRADFORD",
            "state": "PA",
            "postal_code": "167011036",
            "telephone_number": "814-363-9484",
            "fax_number": "814-362-3854"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "OLEAN GENERAL HOSPITAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-01-27",
        "last_updated": "2023-10-10",
        "certification_date": "2023-10-10",
        "status": "A",
        "authorized_official_last_name": "OWENS",
        "authorized_official_first_name": "JILL",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "716-373-2600",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "PA",
            "license": null,
            "primary": true
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "PA",
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1007755030029",
            "state": "PA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "03927699",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Foothills Medical Group at BRMC RHC",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "Foothills Medical Group at BRMC RHC",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Bradford, PA

Sources for this page

Verify at the official NPI Registry.