Basic Information
| Provider Information | |||||||||
| NPI: | 1386769545 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GAUDENZIA INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GAUDENZIA WESTSHORE OUTPATIENT SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 106 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | NORRISTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194014716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102399600 | ||||||||
| FaxNumber: | 6102757025 | ||||||||
| Practice Location | |||||||||
| Address1: | 4740 DELBROOK RD | ||||||||
| Address2: | |||||||||
| City: | MECHANICSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170503041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177668517 | ||||||||
| FaxNumber: | 7177960196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 03/10/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR. CONTRACTING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4843383731 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 211144 | PA | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 1002285890084 | 05 | PA | MEDICAID | 1002285890080 | 05 | PA | MEDICAID |