Basic Information
| Provider Information | |||||||||
| NPI: | 1063407096 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEST GROVE HOSPITAL CORPORATION | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | JENNERSVILLE REGIONAL HOSPITAL HOME SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 BELL TOWER LN | ||||||||
| Address2: | |||||||||
| City: | OXFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193631208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109981700 | ||||||||
| FaxNumber: | 6109981799 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 BELL TOWER LN | ||||||||
| Address2: | |||||||||
| City: | OXFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193631208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109981700 | ||||||||
| FaxNumber: | 6109981799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2005 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BUONOMO | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 6109981700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WEST GROVE HOSPITAL CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 740005 | PA | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 58150671002 | 01 | PA | TRICARE PROV # | OTHER | 0000804000 | 01 | PA | BLUE CROSS PROVIDER # | OTHER | 1007312400008 | 05 | PA | MEDICAID | 1152927 | 01 | PA | KEYSTONE MERCY HEALTH PLA | OTHER |