Basic Information
| Provider Information | |||||||||
| NPI: | 1184625360 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LEHIGH VALLEY HOSPITAL - SCHUYLKILL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SCHUYLKILL MEDICAL CENTER - SOUTH JACKSON STREET CRNA GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 S JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | POTTSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 179013625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706215000 | ||||||||
| FaxNumber: | 5706228221 | ||||||||
| Practice Location | |||||||||
| Address1: | 420 S JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | POTTSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 179013625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706215000 | ||||||||
| FaxNumber: | 5706228221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 06/27/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARCHOZZI | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EVP &CFO | ||||||||
| AuthorizedOfficialTelephone: | 4848623943 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 421001 | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1373786 | 01 | PA | BLUE SHIELD - ANESTHESIA | OTHER |