Basic Information
| Provider Information | |||||||||
| NPI: | 1720268527 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EVANGELICAL MEDICAL SERVICES ORGANIZATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EMSO SELINSGROVE LAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178379315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705224134 | ||||||||
| FaxNumber: | 5705224120 | ||||||||
| Practice Location | |||||||||
| Address1: | 935 ROUTE 522 | ||||||||
| Address2: | |||||||||
| City: | SELINSGROVE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178709714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703726102 | ||||||||
| FaxNumber: | 5703726110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2007 | ||||||||
| LastUpdateDate: | 11/08/2007 | ||||||||
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| AuthorizedOfficialLastName: | AUCKER | ||||||||
| AuthorizedOfficialFirstName: | KENDRA | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5705222807 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | PA | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 1007498260041 | 05 | PA | MEDICAID |