Basic Information
| Provider Information | |||||||||
| NPI: | 1467510560 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAGLEVILLE HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 100 EAGLEVILLE RD | ||||||||
| Address2: | |||||||||
| City: | EAGLEVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194031829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105396000 | ||||||||
| FaxNumber: | 6105396249 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 EAGLEVILLE RD | ||||||||
| Address2: | |||||||||
| City: | EAGLEVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194031829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105396000 | ||||||||
| FaxNumber: | 6105396249 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 02/11/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCGLONE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2672912210 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 051001 | PA | N | Hospitals | General Acute Care Hospital | 284300000X | 051001 | PA | N | Hospitals | Special Hospital | 276400000X | 051001 | PA | Y | Hospital Units | Rehabilitation, Substance Use Disorder Unit |
ID Information
| ID | Type | State | Issuer | Description | 1007779290003 | 05 | PA | MEDICAID | 106359 | 01 | PA | CBH | OTHER | EAGL1977 | 01 | PA | COMPREHENSIVE BEHAV CARE | OTHER | 128150 | 01 | PA | MBH OF PA, INC. | OTHER | 0001185000 | 01 | PA | INDEPENDENCE BLUE CROSS | OTHER | 004418000 | 01 | PA | MAGELLAN BEHAVIORAL HLTH | OTHER |