Basic Information
| Provider Information | |||||||||
| NPI: | 1649271842 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LEHIGH VALLEY HOSPITAL - SCHUYLKILL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE POTTSVILLE HOSPITAL AND WARNE CLINIC PATHOLOGY | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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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: | 08/10/2005 | ||||||||
| LastUpdateDate: | 01/29/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARCHOZZI | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EVP &CFO | ||||||||
| AuthorizedOfficialTelephone: | 4848623943 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0105X | 421001 | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1364071 | 01 | PA | BLUE SHIELD - PATHOLOGY | OTHER |