NPIMap

Organization Active NPI

Port Allegany Area Family Practice PC

  • Rural Health Clinic/Center
  • Port Allegany, PA
National Provider Identifier
1962469486
Registry record updated Jun 22, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
PORT ALLEGANY AREA FAMILY PRACTICE PC
Practice address
1 Willow St
Port Allegany, PA 16743-1332
Phone
(814) 642-9531
Fax
(814) 642-2020
NPI assigned
Apr 27, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 22, 2022

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

Authorized official

Name
Mark H Shelley, M.D.NPI 1336106954
Title
President
Phone
(814) 642-9531

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 5

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X MD029656E PA
Rural Health Clinic/Center 261QR1300X Primary
Medical Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 363AM0700X MA053689 PA
Family Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LF0000X SP008214 PA
Family Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LF0000X SP009929 PA

Addresses

Primary practice location

1 Willow St
Port Allegany, PA 16743-1332

Mailing address

1 Willow St
Port Allegany, PA 16743-1332
Phone (814) 642-9531

Other identifiers 3

IdentifierTypeStateIssuer
CF9006OtherRAILROAD MEDICARE
0014032880001MedicaidPA
861827OtherPAHIGHMARK BLUE SHIELD

Other names 1

  • UPPER ALLEGHENY MEDICAL CENTER Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040621000590 PA Part B Supplier - Clinic/Group Practice 4789669144 Receives reassigned benefits from 4 practitioners
Practice locations: Port Allegany, PA
O20100331000102 PA Part A Provider - Rural Health Clinic 4789669144 Practice locations: Port Allegany, PA

Rural health clinic certification: CCN 393849

Legal name
PORT ALLEGANY AREA FAMILY PRACTICE PC
Doing business as
UPPER ALLEGHENY MEDICAL CENTER
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Nov 17, 1992
Last certification
Nov 8, 2021
Ownership / control type
1B
Organization structure
CorporationProprietary
Incorporated
Nov 1, 1980 in PA
Enrollment address
1 Willow St
Upper Allegheny Medical Center
Port Allegany, PA 16743-1332

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
39D0662965Port Allegany Family Practice1 Willow Street, Port Allegany, PA 16743Provider-performed microscopyJun 24, 2028

National Provider Directory

National Provider Directory

Locations

1 Willow St
Port Allegany, PA 16743
Phone (814) 642-9531

1 Willow St
Uppr
Port Allegany, PA 16743
Phone (814) 642-9531

Ownership & related parties

All disclosed owners & managing parties 2

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

NameRoleSinceShare
Tracy Smith Individual W-2 Managing Employee Jan 1, 2022
Mark Shelley Individual Corporate Director Jan 1, 2009 100%

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1146096000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1655856000000",
    "number": "1962469486",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1 WILLOW ST",
            "city": "PORT ALLEGANY",
            "state": "PA",
            "postal_code": "167431332",
            "telephone_number": "814-642-9531",
            "fax_number": "814-642-2020"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1 WILLOW ST",
            "city": "PORT ALLEGANY",
            "state": "PA",
            "postal_code": "167431332",
            "telephone_number": "814-642-9531",
            "fax_number": "814-642-2020"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PORT ALLEGANY AREA FAMILY PRACTICE PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-04-27",
        "last_updated": "2022-06-22",
        "certification_date": "2022-06-22",
        "status": "A",
        "authorized_official_last_name": "SHELLEY",
        "authorized_official_first_name": "MARK",
        "authorized_official_middle_name": "H",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "814-642-9531",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "PA",
            "license": "MD029656E",
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363AM0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant, Medical",
            "state": "PA",
            "license": "MA053689",
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": "PA",
            "license": "SP008214",
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": "PA",
            "license": "SP009929",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "CF9006",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0014032880001",
            "state": "PA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HIGHMARK BLUE SHIELD",
            "identifier": "861827",
            "state": "PA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "UPPER ALLEGHENY MEDICAL CENTER",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "UPPER ALLEGHENY MEDICAL CENTER",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Port Allegany, PA

Sources for this page

Verify at the official NPI Registry.