Basic Information
| Provider Information | |||||||||
| NPI: | 1629303961 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SCHUYLKILL MEDICAL CENTER - SOUTH JACKSON STREET | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SCHUYLKILL MEDICAL CENTER - SOUTH JACKSON STREET TCU | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| 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: | 10/05/2009 | ||||||||
| LastUpdateDate: | 10/05/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SIMODEJKA | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 5706215000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.