Basic Information
| Provider Information | |||||||||
| NPI: | 1093720948 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MUHLENBERG HOSPITAL CENTER | ||||||||
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| OtherOrganizationName: | BASE SERVICE UNIT 392 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1650 VALLEY CENTER PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180172344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4848844436 | ||||||||
| FaxNumber: | 4848844444 | ||||||||
| Practice Location | |||||||||
| Address1: | 2604 SCHOENERSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180173518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106918028 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2006 | ||||||||
| LastUpdateDate: | 10/19/2007 | ||||||||
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| AuthorizedOfficialLastName: | KAUFMAN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6108669000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MUHLENBERG HOSPITAL CENTER | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 1041C0700X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 364S00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | 2084P0800X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1368384 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER |