Basic Information
Provider Information | |||||||||
NPI: | 1457350548 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LEHIGH VALLEY HOSPITAL - SCHUYLKILL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | THE POTTSVILLE HOSPITAL AND WARNE CLINIC (HOME HEALTH) | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 07/20/2005 | ||||||||
LastUpdateDate: | 07/19/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MARCHOZZI | ||||||||
AuthorizedOfficialFirstName: | THOMAS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EVP & CFO | ||||||||
AuthorizedOfficialTelephone: | 4848623943 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 421001 | PA | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | 100760725-0010 | 05 | PA |   | MEDICAID | 1499 | 01 | PA | HIGHMARK/BLUE SHIELD | OTHER | 39-7214 | 01 | PA | CAPITAL BLUE CROSS | OTHER |