Basic Information
| Provider Information | |||||||||
| NPI: | 1073770012 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CROZER-KEYSTONE HEALTH SYSTEM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 W SPROUL RD | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190642027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103288700 | ||||||||
| FaxNumber: | 6104476620 | ||||||||
| Practice Location | |||||||||
| Address1: | 190 W SPROUL RD | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190642027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103288700 | ||||||||
| FaxNumber: | 6104476620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2008 | ||||||||
| LastUpdateDate: | 01/23/2014 | ||||||||
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| AuthorizedOfficialLastName: | GAVIN | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 6103388228 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 037201 | PA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 484029 | 01 | PA | AETNA | OTHER |