Basic Information
| Provider Information | |||||||||
| NPI: | 1508966722 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EVANGELICAL MEDICAL SERVICES ORGANIZATION | ||||||||
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| OtherOrganizationName: | EMSO PATHOLOGY GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 HOSPITAL DR | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | LEWISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178379350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705224110 | ||||||||
| FaxNumber: | 5707683911 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178379350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705224110 | ||||||||
| FaxNumber: | 5707683911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 10/14/2015 | ||||||||
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| AuthorizedOfficialLastName: | AUCKER | ||||||||
| AuthorizedOfficialFirstName: | KENDRA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 5705222807 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | PA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0101X | PA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology |
ID Information
| ID | Type | State | Issuer | Description | 02533600 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 02533600 | 01 | PA | KEYSTONE | OTHER | 1007498260054 | 05 | PA | MEDICAID | 29496 | 01 | PA | HEALTH AMERICA | OTHER | 725334 | 01 | PA | GEISINGER | OTHER | 001881627 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER |