Basic Information
| Provider Information | |||||||||
| NPI: | 1548269632 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LEHIGH VALLEY HOSPITAL - SCHUYLKILL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE POTTSVILLE HOSPITAL AND WARNE CLINIC PSYCHIATRIC UNIT | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 E NORWEGIAN ST | ||||||||
| Address2: | |||||||||
| City: | POTTSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 179012710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706214003 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 420 S JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | POTTSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 179013625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706215000 | ||||||||
| FaxNumber: | 5706218221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2005 | ||||||||
| LastUpdateDate: | 11/01/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REPPY | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5706214003 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 421001 | PA | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 39-S030 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 1498 | 01 | PA | HIGHMARK/BLUE SHIELD | OTHER | 100760725-0011 | 05 | PA | MEDICAID |