Provider Demographics
NPI:1588272884
Name:MILLCREEK MANOR
Entity type:Organization
Organization Name:MILLCREEK MANOR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BEERBOWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-488-4825
Mailing Address - Street 1:5535 PEACH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-2603
Mailing Address - Country:US
Mailing Address - Phone:814-868-2496
Mailing Address - Fax:814-868-2581
Practice Address - Street 1:5535 PEACH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-2603
Practice Address - Country:US
Practice Address - Phone:814-868-2496
Practice Address - Fax:814-868-2581
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LECOM HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-07-22
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes333600000XSuppliersPharmacy
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012079290002Medicaid