Basic Information
| Provider Information | |||||||||
| NPI: | 1225097652 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. CHARLES HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 95000-6570 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191956570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314746000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 BELLE TERRE ROAD | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117145713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314746000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 11/17/2016 | ||||||||
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| AuthorizedOfficialLastName: | VASIL | ||||||||
| AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6317476116 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 000200 | 01 | NY | BLUE CROSS | OTHER |