Basic Information
Provider Information | |||||||||
NPI: | 1588763841 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KELLER ARMY COMMUNITY HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TOBYHANNA PHCY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 900 WASHINGTON RD | ||||||||
Address2: | ATTN MCUD-RMD-UBO | ||||||||
City: | WEST POINT | ||||||||
State: | NY | ||||||||
PostalCode: | 109961109 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8459388239 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 11 HAP AMOLD BLVD | ||||||||
Address2: |   | ||||||||
City: | TOBYHANNA | ||||||||
State: | PA | ||||||||
PostalCode: | 18466 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5708957225 | ||||||||
FaxNumber: | 5708956783 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2006 | ||||||||
LastUpdateDate: | 03/23/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MORALES | ||||||||
AuthorizedOfficialFirstName: | HECTOR | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MGR PHRMCY OPERATIONS CNTR | ||||||||
AuthorizedOfficialTelephone: | 2102218443 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | KELLER ARMY COMMUNITY HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332000000X |   |   | Y |   | Suppliers | Military/U.S. Coast Guard Pharmacy |   |
ID Information
ID | Type | State | Issuer | Description | 005609 | 01 |   | PAYMENT CENTER | OTHER | 3979070 | 01 |   | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER | 1528161916 | 01 |   | PARENT BILLING NPI | OTHER |