Basic Information
| Provider Information | |||||||||
| NPI: | 1013985126 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JEFFERSON HOSPITAL | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 565 COAL VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | CLAIRTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150253703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4122056050 | ||||||||
| FaxNumber: | 4122056472 | ||||||||
| Practice Location | |||||||||
| Address1: | 565 COAL VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | CLAIRTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150253703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4124695000 | ||||||||
| FaxNumber: | 4122056472 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | FRIES | ||||||||
| AuthorizedOfficialFirstName: | RICK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 4123302472 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | PA | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 0968 | 01 | PA | HIGHMARK BLUE CROSS | OTHER | 100744347052 | 05 | PA | MEDICAID |