Basic Information
| Provider Information | |||||||||
| NPI: | 1124023015 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NAZARETH HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2601 HOLME AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191522007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2153356000 | ||||||||
| FaxNumber: | 2153356303 | ||||||||
| Practice Location | |||||||||
| Address1: | 2601 HOLME AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191522007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2153356000 | ||||||||
| FaxNumber: | 2153356303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 06/25/2019 | ||||||||
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| AuthorizedOfficialLastName: | WAJDA | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER, VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2153356043 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 400301 | PA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1007654720011 | 05 | PA | MEDICAID | P030272 | 01 | PA | CHAMPUS | OTHER |