Basic Information
| Provider Information | |||||||||
| NPI: | 1134114119 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EVANGELICAL AMBULATORY SURGICAL CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 JPM RD | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178379367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705246700 | ||||||||
| FaxNumber: | 5705246710 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 JPM RD | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178379367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705246700 | ||||||||
| FaxNumber: | 5705246710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2005 | ||||||||
| LastUpdateDate: | 04/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | MALONEY | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5705246700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 14631501 | PA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1007755680001 | 05 | PA | MEDICAID | 20025739 | 01 | PA | AMERIHEALTH PROVIDER NUMB | OTHER | 39C0001119 | 01 | PA | STERLING OPTION I | OTHER | 79197 | 01 | PA | GEISINGER HEALTH PLAN | OTHER | 0167726 | 01 | PA | DEPARTMENT OF LABOR PROV# | OTHER | 155458XX | 01 | PA | PREFERRED CARE | OTHER | 151805 | 01 | PA | HEALTH AMERICA PROV# | OTHER | 390839 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 1599 | 01 | PA | HIGHMARK BLUESHIELD | OTHER | 490005320 | 01 | PA | RAILROAD MEDICARE | OTHER |